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College  ot  $i)2>gtctansi  anb  burgeons 


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DISEASES 


OF   THE 


DIGESTIVE  ORGANS 


WITH  SPECIAL  REFERENCE  TO  THEIR 


DIAGNOSIS  AND  TEEATMENT 


BY 

CHARLES  D.  AARON,  Sc.D.,  M.D.,  F.A.C.P. 

PROFESSOR  OF  GASTROENTEROLOGY  AND  DIETETICS  IN    THE   DETROIT    COLLEGE    OF    MEDICINE 
AND    SURGERY:  CONSULTING  GASTROENTEROLOGIST  TO    HARPER    HOSPITAL 


THIRD  EDITION,  THOROUGHLY  REVISED 


ILLUSTRATED  WITH  164  ENGRAVINGS,  48  ROENTGENOGRAMS 
AND  13  COLORED  PLATES 


LEA  &  FEBIGER 

PHILADELPHIA    AND    NEW   YORK 
1921 


J 


Copyright 
LEA  &  FEBIGER 

1921 


PRINTED  IN  U.  S.  A. 


PREFACE  TO  THE  THIRD  EDITION. 


The  general  view  expressed  in  the  preface  to  the  second  edition 
of  this  work,  that  the  profession  at  large  was  becoming  increasingly 
interested  in  the  subject  of  gastroenterology,  has  been  amply  con- 
firmed by  the  call  for  a  third  edition.  Every  physician  should  be 
acquainted,  if  not  with  all  the  details  set  forth  herein,  at  least 
with  the  fact  that  diseases  of  the  digestive  organs  can  be  accurately 
diagnosed  and  the  prospect  of  recovery  thereby  very  materially 
enhanced.  Moreover,  while  personal  instruction  is  the  ideal  train- 
ing method,  the  hope  entertained  by  the  author  that  the  text  and 
the  illustrations  accompanying  it  would  place  at  the  command  of 
the  practitioner  a  fair  proportion  of  the  results  attained  by  special 
research  has  been  more  than  justified  by  the  history  of  the  two 
previous  editions.  In  the  interests  of  medical  science  this  demand 
of  the  profession  for  definite  information  is  satisfying  in  a  larger 
sense  than  merely  an  author's  gratification. 

Several  new  colored  plates,  roentgenograms,  engravings  and  a 
considerable  amount  of  new  material  have  been  incorporated  in 
this  edition,  reflecting  the  progress  that  has  been  made  in  recent 
years  in  this  branch  of  medicine;  and  several  matters  which  could 
only  be  outlined  in  previous  editions  have  been  made  the  subject 
of  detailed  discussion. 

The  plan  of  the  work,  as  before,  follows  the  physiologic  path 
of  the  digestive  tract,  beginning  with  diseases  of  the  mouth,  and 
taking  up  in  succession  the  pharynx,  esophagus,  stomach,  liver, 
gall  bladder,  bile  ducts,  pancreas,  small  intestine,  vermiform 
appendix,  cecum,  colon,  sigmoid  flexure,  rectum,  and  anus.  The 
author  has  attempted  to  put  before  the  practitioner,  in  an  orderly, 
consecutive  manner,  the  diagnosis  and  treatment  of  digestive 
diseases,  and  to  make  available  all  the  resources  at  his  command. 
There  is  an  unfortunate  tendency  nowadays  to  isolate  the  consid- 
eration of  diseases  of  the  digestive  organs  from  the  great  body  of 
internal  medicine.     But  there  is  a  direct  connection  between  the 


4  PREFACE  TO  THE  THIRD  EDITION 

functions  of  the  digestive  tract  and  the  functions  of  other  organs, 
and  this  fact  of  interdependence  is  of  prime  significance  in  gastro- 
enterologic  pathology.  The  author  has  endeavored  to  reaffirm 
the  intimate  relationship  between  gastroenterology  and  the  other 
branches  of  internal  medicine. 

No  subject  has  profited  more  by  the  modern  spirit  of  scientific 
research  than  the  diagnosis  and  treatment  of  diseases  of  the  diges- 
tive organs.  Many  new  methods  of  investigation,  physical,  chem- 
ical, microscopical  and  clinical,  have  sharpened  our  vision  and 
given  us  certainty  in  dealing  with  obscure  pathologic  processes. 
Without  the  least  inclination  to  discourage  research,  but  rather 
with  a  profound  desire  to  stimulate  it,  the  author  has  striven  to 
eliminate  abstract  theories  and  to  present  to  the  practitioner  only 
the  practical,  the  trustworthy  and  the  helpful.  The  book  is 
intended  not  only  as  an  aid  to  the  specialist  in  diseases  of  the 
digestive  organs,  but  also  as  a  ready  reference  work  for  the  general 
practitioner  and  surgeon. 

The  physiology  of  digestion  has  been  considered  from  the  view- 
point of  the  clinician  rather  than  from  that  of  the  physiologist; 
and  attention  has  been  given  to  recent  progress  in  the  study  of 
internal  secretions,  which  has  contributed  much  to  our  knowledge 
of  the  physiology  of  digestion. 

The  stomach  tube  and  the  qualitative  and  quantitative  analyses 
which  disclose  the  actual  condition  of  the  gastric  functions  have 
become  a  necessity  in  the  diagnosis  of  digestive  disorders.  Space 
has  been  devoted  to  many  tests  and  reactions  for  the  diagnosis  of 
carcinoma,  such  as  the  Wolff- Junghans,  Abderhalden,  Gluzinski, 
Salomon,  tryptophan,  hemolytic,  antitryptic,  miostagmin,  cyto- 
diagnostic,  blood-sugar  tolerance,  and  others. 

By  the  use  of  the  duodenal  tube  the  contents  of  the  duodenum 
have  become  available  and  subject  to  analysis,  as  in  the  case  of 
the  gastric  contents.  A  chapter  is  devoted  to  the  employment  of 
the  tube  for  draining  the  gall  bladder  and  bile  ducts,  duodenal 
lavage,  duodenal  feeding,  removal  of  the  duodenal  contents,  and 
examination  of  the  latter.  The  several  duodenal  tubes  in  use,  each 
with  its  own  advantages,  are  fully  described.  With  reference  to 
examination  of  the  duodenal  enzymes,  their  reactions  in  health  and 
disease  are  shown  in  colored  plates,  so  that  the  practitioner  can 
easily  check  up  his  tests. 

Recent  methods  of  examining  the  feces  to  determine  the  condi- 


PREFACE  TO   THE  THIRD  EDITION 

tion  of  the  intestinal  function  arc  indispensable  to  the  physician 

who  would  deal  successfully  with  affections  of  the  digestive  organs. 
These  new  procedures  are  particularly  valuable  in  cas<  s  in  which  the 
subjective  sensations  or  symptoms  arc  indistinct  or  absent.  With 
the  diagnostic  technic  now  available  for  the  examination  of  the 
fe<e->  after  a  test  diet,  we  can  determine  the  origin,  formerly  obscure, 
of  many  disturbances  of  the  intestine.  The  diagnostician  i-  now 
able  to  detect  the  more  minute  disturbances  of  absorption,  secre- 
tion and  motility,  and  institute  rational  treatment.  The  test-diet 
stool  findings  in  each  one  of  the  diseases  of  the  digestive  organs 
are  fully  explained  in  due  order. 

Roentgenography  of  the  esophagus,  stomach  and  intestine  shows 
location,  relations  form,  dimensions  and  muscular  functions  of 
these  organs.  The  Roentgen  ray  has  brought  an  element  of  exact- 
ness into  diagnosis,  making  exploratory  laparotomy  often  unneces- 
sary. One  chapter,  equipped  with  copious  illustrations,  is  devoted 
to  this  important  subject.  For  the  roentgenograms  I  am  indebted 
to  Dr.  P.  M.  Hickey  and  Dr.  W.  A.  Evans,  of  this  city. 

Dietetic  treatment  in  its  various  subdivisions  is  dealt  with,  and 
in  the  discussion  of  the  treatment  of  each  pathologic  condition 
the  respective  dietary  directions  are  given.  Besides  details  as  to 
the  importance  of  the  vitamins,  comprehensive  tables  of  caloric 
values  are  included  in  this  section  of  the  work.  One  chapter  has 
been  devoted  to  diet  in  typhoid  fever,  with  special  reference  to 
the  high  caloric  feeding  now  favored  by  many  clinicians. 

The  principles  and  the  details  of  massage  of  the  stomach  and 
intestine  deserve  special  consideration.  The  technic  of  massage  is 
minutely  described  and  the  manipulations  illustrated. 

Convinced  of  the  importance  of  hydrotherapeutic  measures  the 
efficacy  of  which  depends  on  temperature,  method,  timeliness, 
duration,  etc.,  the  author  has  presented  them  as  fully  as  the  scope 
of  the  volume  permitted,  and  has  added  practicable  suggestions 
for  the  use  of  packs,  baths.,  compresses,  and  douches.' 

Mineral  waters  represent  a  considerable  part  of  gastrointestinal 
therapy.  Though  the  American  waters  are  fairly  well  known,  they 
are  not  fully  appreciated.  It  is  not  necessary  that  a  patient  be 
sent  across  the  seas  for  something  that  can  be  secured  at  home. 
The  author  has  given  in  brief  compass  a  list  of  native  and  foreign 
waters  available  for  use  in  gastro-intestinal  affections,  together 
with  recommendations  in  regard  to  their  use. 


6  PREFACE  TO  THE  THIRD  EDITION 

The  moist  heat  prevailing  in  the  mouth  furnishes  a  most  favor- 
able condition  for  the  growth  of  microorganisms.  Such  diseases 
as  syphilis,  tuberculosis,  leukoplakia,  stomatitis,  and  affections  of 
the  tongue,  tonsils,  salivary  glands,  salivary  ducts,  alveolar  pro- 
cesses, lips  and  gums,  make  the  mouth  a  focus  of  infection.  During 
mastication  the  bacteria  are  squeezed  out  of  the  pathologic  tissue 
and  carried  with  the  food  into  the  stomach  and  intestine.  Recent 
experiments  on  the  lower  animals  prove  that  the  intravenous 
injection  of  specific  microorganisms  cultivated  from  the  tonsils 
and  apical  abscesses  of  the  teeth  may  induce  gastric  and  duodenal 
ulcer,  cholangitis,  cholecystitis,  pancreatitis,  appendicitis,  myo- 
carditis, arthritis,  goiter,  and  enlarged  glands.  Focal  infection  is 
certainly  a  predominating  factor  in  the  etiology  of  many  gastro- 
intestinal diseases.  Hence  the  great  importance  of  the  early 
detection  and  treatment  of  variations  from  the  normal  in  the  vesti- 
bule of  the  digestive  tract. 

The  diagnosis  and  treatment  of  the  many  pathologic  changes  of 
the  esophagus  have  been  greatly  advanced  by  new  methods.  They 
can  now  be  diagnosed  by  means  of  bougies,  the  esophagoscope,  and 
the  Roentgen  ray.  Through  the  esophagoscope  we  can  apply  local 
treatment  directly  to  the  esophagus.  Varieties  of  esophagitis, 
ulcers,  neoplasms,  strictures,  spasms,  diverticula,  dilatation,  rup- 
ture, perforation,  malacia,  hemorrhage,  neuroses,  parasites  and 
foreign  bodies,  are  discussed  in  the  chapter  on  diseases  of  the 
esophagus. 

It  is  often  difficult  to  establish  the  diagnosis  of  a  nervous  or 
functional  derangement  of  the  digestive  organs;  an  understanding 
of  the  vegetative  nervous  system  is  here  of  great  assistance. 
These  nerves  can  be  stimulated  and  inhibited  by  certain  medica- 
ments. In  connection  with  this  subject  the  opposing  conditions, 
vagotonia  and  sympathicotonia,  are  elaborated  and  their  important 
signs  and  symptoms  tabulated.  Pharmacodynamic  and  physiologic 
tests  for  the  diagnosis  of  disturbances  of  the  vegetative  nervous 
system  are  given  in  detail,  so  that  the  clinician  may  be  enabled  to 
employ  them  readily.  Neuroses  of  the  digestive  organs  resulting 
in  motor  disturbances,  sensory  disturbances,  and  secretory  disturb- 
ances, are  discussed. 

Besides  the  several  chapters  on  gastric  disorders  classed  as 
neuroses,  attention  is  given  to  gastritis,  motor  insufficiency,  gastric 
ulcer,   gastric   and  intestinal  hemorrhage,   erosions,  perigastritis, 


PREFACE  OF  Till-:  THIRD  EDITION  7 

arteriosclerosis,  syphilis,  tuberculosis,  and  tumors  of  the  stomach, 

in  separate  chapter^ 

Recent  discoveries  have  shown  that  the  liver  and  pancreas 
possess  manifold  functions  in  the  economy  of  metabolism.  An 
injury  to  their  structure  brings  about  a  functional  disturbance. 
The  clinical  ensemble  of  diseases  of  the  liver,  gall  bladder  and 
pancreas  has  been  brought  into  clearer  light,  and  the  medical  treat- 
ment broadened  by  rational  methods.  Chapters  XXXIII,  XXXIY 
and  XXXV  contain  a  summary  of  present-day  knowledge  on  this 
subject. 

In  the  chapter  devoted  to  gastroenteroptosis  the  complications 
of  kinks,  bends,  loops,  redundancy,  adhesions,  bands,  membranes, 
and  cecum  .mobile  are  considered.  In  addition  to  the  physical, 
electrotherapeutic,  hydrotherapeutic,  mechanical  and  medicinal 
treatment  of  gastroenteroptosis,  hyperalimentation  is  discussed  in 
detail. 

Separate  chapters  cover  the  important  subjects  of  acute  entero- 
colitis, chronic  enterocolitis,  enteritis  membranacea,  chronic  diar- 
rhea, and  chronic  constipation.  The  subject  of  chronic  constipa- 
tion has  been  divided  into  atonic,  spastic,  and  fragmentary. 
Because  of  its  importance,  a  chapter  is  devoted  to  duodenal  ulcer. 
Catarrhal,  follicular,  tubercular  and  syphilitic  ulcers  of  the  intes- 
tine are  also  considered  at  length.  Another  chapter  deals  with 
chronic  intestinal  toxemia,  chronic  intestinal  stasis,  and  ileal  regur- 
gitation, and  their  medical  and  surgical  treatment.  Since  the 
accumulation  of  gas  is  a  symptom  in  many  diseases  of  gastro- 
intestinal origin,  a  chapter  on  flatulence,  meteorism  and  tympanites 
has  become  necessary;  both  exogenous  and  endogenous  gases  are 
considered  and  their  respective  treatments  given. 

Obstructions  of  the  intestine  due  to  kinks,  adhesions,  mem- 
branes and  tumors,  as  well  as  those  due  to  strangulation,  intus- 
susception, volvulus  and  foreign  bodies,  are  considered.  A  chapter 
has  been  assigned  to  stricture  of  the  intestine.  Tumors  of  the 
intestine,  appendicitis,  nervous  diseases  of  the  intestine,  peri- 
sigmoiditis, diverticulitis,  sigmoiditis,  and  idiopathic  dilatation  of 
the  colon  are  considered  in  separate  chapters. 

Uncinariasis,  which  is  nowT  the  subject  of  widespread  medical 
interest,  is  included  in  the  chapter  dealing  with  animal  parasites 
of  the  intestine. 

The  diagnosis  and  treatment  of  diseases  of  the  rectum  and  anus 


8  PREFACE  TO  THE  THIRD  EDITION 

are  generally  left  in  the  hands  of  the  surgeon.  While  in  this 
volume  the  viewpoint  of  the  internist  with  regard  to  these  diseases 
is  set  forth,  explicit  mention  is  also  made  of  such  cases  as  require 
surgical  intervention.  Hemorrhoids,  malignant  and  benign 
growths,  stricture,  proctitis,  ulcers,  prolapse,  proctospasm,  and 
paralysis  of  the  rectum  are  considered  in  detail.  Both  medical 
and  surgical  treatment  is  also  given  for  coccygodynia,  pruritus, 
fistula,  and  fissure  of  the  anus. 

The  author  indulges  the  hope  that  this  work,  revised  and  enlarged 
in  this  third  edition,  may  be  found  worthy  of  a  kind  reception. 
To  the  many  writers  who  have  preceded  him  he  acknowledges 
his  indebtedness  with  hearty  appreciation.  And  to  the  foreign 
writers  whose  scientific  idealism  has  done  so  much  to  maintain  the 
reputation  of  medicine  as  a  dignified  and  progressive  vocation, 
he  wishes  to  express  his  great  respect.  He  disclaims  for  this 
attempted  clarification  of  the  mass  of  experiment  and  observation 
which  has  enriched  the  closing  years  of  the  nineteenth  and  the 
opening  years  of  the  twentieth  century  any  more  pretentious 
merit  than  that  of  fidelity  to  fact  and  adherence  to  logical  sequence, 
accompanied,  as  the  scope  of  the  work  has  allowed,  with  a  recital 
of  his  personal  contributions  to  the  sum  total  of  the  working 
capital  of  the  profession. 

C.  D.  A. 

Detroit,  1921. 


CONTENTS. 


CHAPTER  I. 

The  Physiology  of  Digestion. 

Salivary  Digestion 49 

Action  of  the  Saliva 49 

PtyaliD 50 

Amy  lode  xtrin 50 

Erythrodextrin    ...  ■      •  50 

Achroodextrin 50 

Maltose 50 

Dextrose 50 

Movements  of  the  Stomach 50 

Gastric  Digestion 52 

Enzymes  .  53 

Pepsin 54 

Hydrochloric  Acid 54 

Normal  Gastric  Juice 54 

Secretin •      •  55 

Pepsin 55 

Rennin 56 

Lipase 56 

Absorptive  Power  of  the  Stomach 56 

Intestinal  Digestion 56 

Digestion  by  the  Small  Intestine  ....  56 

Pancreatic  Juice 57 

Prosecretin 57 

Secretin 57 

Trypsin ....       57 

Enterokinase 58 

Amylopsin 58 

Steapsin 58 

The  Bile 58 

Biliary  Acids 58 . 

Biliary  Pigments •      •      •       58 

Cholesterol 59 

The  Intestinal  Juice       ....  59 

Maltase  ........-.-• 59 

Lactase •  .59 

Invertin •      •       59 

Erepsin 59 

Enterokinase 59 

Cytase 59 

Absorption  in  the  Small  Intestine 60 

Protein  Absorption 60 


10  CONTENTS 

Intestinal  Digestion — 

Absorption  in  the  Small  Intestine — ■ 

Fat  Absorption .  60 

Carbohydrate  Absorption 61 

Cellulose  and  Hemicellulose  Absorption 61 

Absorption  of  Aqueous  and  Saline  Solutions 61 

Digestion  and  Absorption  in  the  Large  Intestine 61 

Intestinal  Movements 62 

Segmenting 62 

Peristaltic 62 

Pendulum ' 63 

Anastalsis 63 

Keith  Nodal  Tissue 63 

Law  of  Contrary  Innervation 65 

Feces 65 

CHAPTER  II. 

Examination  of  the  Stomach  Contents. 

Stomach  Contents 66 

Test  Meals 67 

Ewald-Boas  Test  Breakfast      .            67 

Boas  Test  Breakfast 67 

Riegel  Test  Dinner  .            68 

Macroscopic  Examination  of  Stomach  Contents 68 

Methods  of  Obtaining'  Stomach  Contents 68 

Expression 68 

Aspiration 68 

Author's  Improved  Stomach  Tube. 68 

Einhorn  Stomach  Bucket 70 

Regurgitation 71 

Inspection  of  Stomach  Contents 72 

Determination  of  Gastric  Juice 73 

Color 73 

Odor 74 

Consistency .  74 

Chemical  Examination  of  Stomach  Contents        ........  74 

Apparatus 74 

Determination  of  Reaction 75 

Dimethylamidoazobenzol  Test 75 

Gtinzburg's  Test 76 

Quantitative  Analysis  of  Stomach  Contents 76 

Normal  Solutions 77 

Fractional  Analysis 78 

Rehfuss  Gastroduodenal  Tube 78 

Test  Breakfast  Secretory  Curve     ..." 79 

Phenolphthalein  Test  for  Total  Acidity 79 

Topfer's  Method  of  Quantitative  Analysis 80 

Combined  Hydrochloric  Acid ". 81 

Lactic  Acid 82 

Uffelmann's  Test •   .      .  82 

Strauss'  Test 83 


coXTVVfS  ll 

Examination  of  Enzymes 83 

Pepsinogen  and  Pepsin 83 

Determination  of  Pepsin 83 

Jacoby-Sohns  Test 83 

Mett's  Test 84 

The  Gelatin  Test 84 

Qualitative  Test  for  Rennin 84 

Test  for  Propeptone 85 

Test  for  Peptone       ...... 85 

Carbohydrate  Digestion  in>  the  Stomach 85 

Blood  in  the  Stomach  Contents 86 

Weber's  Guaiac  Test      ....           ..........  86 

Tests  for  Carcinoma 86 

Salomon's  Test 86 

Wolff  and  Junghans  Test 87 

Cytodiagnosis 87 

Glycyltryptophan  Test 87 

Gluzinski's  Test 88 

Indirect  Methods  of  Gastric  Analysis 88 

Benedict's  Effervescence  Test  for  Acidity           : 88 

Thread  Test  for  Acidity 88 

Friedrich's  Test .      .           .      .  89 

Quantitative  Acidity  Test 89 

Gunzburg's  Test  for  the  Absorptive  Power  of  the  Stomach     ...  89 

Sahli's  Desmoid  Test 90 

Motor  Function  of  the  Stomach 90 

Leube  Test  Meal 90 

Chlorophyl  Test :      .      .  91 

Permeability  of  the  Pylorus 91 

Duodenal  Bucket 91 

Microscopic  Examination  of  Stomach  Contents 92 

Changes  in  Gastric  Secretion  Due  to  Pathological  Conditions  ....  94 

Gastric  Neuroses 94 

Hyperacidity;  Hyperclilorhydria 94 

Hypersecretion;  Gastrosuccorrhea ;  Gastrorrhea;  Gastrochylorrhea    .  94 

Acute  Gastritis 95 

Chronic  Gastritis 95 

Achylia  Gastrica 95 

Motor  Insufficiency  (Atony  and  Dilatation) 95 

Pyloric  Stenosis .  96 

Pyloric  Insufficiency      ....  .96 

Gastric  Ulcer       .... 97 

Erosions  of  the  Stomach ...            .      .  97 

Gastric  Carcinoma 97 


CHAPTER  III. 

Examination  of  the  Duodenal  Contents. 

Duodenal  Tubes 98 

Einhorn  Duodenal  Tube 98 


12  CONTENTS 

Duodenal  Tubes — - 

Gross  Duodenal  Tube 100 

Palef ski  Duodenal  Tube 100 

Jutte  Duodenal  Tube 100 

Determination  of  Tube  in  Duodenum 100 

Characteristics  of  Duodenal  Contents -     ...  101 

Urobilin  and  Urobilinogen 101 

Test  Meal  . 101 

Examination  for  Enzymes     .      .      .      .  • 102 

Starch  Agar  Tubes  .      .' 102 

Olive  Oil  Agar  Tubes 102 

Hemoglobin  Agar  Tubes 102 

Mode  of  Procedure 102 

Determination  of  Enzymes 103 

Changes  in  Pathological  Conditions 103 

Eupancreatism 103 

Hyperpancreatism 103 

Hypopancreatism 103 

Dyspancreatism 103 

Heteropancreatism 103 

Direct  Medication 104 

Draining  the  Gall  Bladder  and  Bile  Ducts 104 

Oxygen  Insufflation 105 

Duodenal  Lavage 105 

Apparatus 106 

Technic 106 

Character  of  Irrigating  Fluid 106 

Indications  for  Duodenal  Lavage 107 

Rheumatism,  Sciatica,  etc 107 

Intestinal  Stasis 107 

Bacteriology  of  the  Duodenum 107 

Results  of  Direct  Examination  of  Duodenal  Contents 109 

Gall  Bladder 109 

Cholecystitis 109 

Bile 109 

Obstruction  of  Common  Duct 109 

Bile  and  Pancreatic  Juice 109 

Pancreatitis 109 

Duodenitis 110 

Duodenal  Ulcer  .      . HO 

Typhoid  Fever 110 

Pernicious  Anemia HO 

CHAPTER  IV. 

Examination  of  the  Feces. 

Importance  of  This  Procedure    .      .      ...      .      .      .      .      .    -.      .      .  Ill 

The  Test  Diet  and  Its  Administration 112 

Examination  of  the  Test-diet  Stool 114 

Apparatus 114 

Macroscopic  Examination ..115 


COX  TEXTS  13 

Examination  <>f  the  Test-die!  .Stool — 

Microscopic  Examination [15 

Chemical  Examination        116 

React  ion  'Pest 1  |C, 

Sublimate  Test lie, 

Incubator  Test lid 

Examination  for  Dissolved  Protein 117 

Bacterial  Preparations 1  IS 

The  Normal  Test-diet  Stool 118 

Pathologic  Stools  ami  Their  Significance  in  the  Diagnosis  of  Gastric  and 

Intestinal  Affections 119 

Pathologic  Food  Remnants 119 

Connective  Tissue *  119 

Muscle  Remnants 120 

Fat 120 

Potato  Remnants 121 

Starch 121 

Pathologic  Products  of  the  Intestinal  Wall 121 

Mucus 121 

Soluble  Protein       . ' 121 

Pus 122 

Unchanged  Biliary  Pigment  (bilirubin) 122 

Bacteria 122 

The  Demonstration  of  Blood  in  the  Feces 123 

Occult  Blood 123 

Benzidin  Test  for  Occult  Blood 123 

Phenolphthalein  Ring  Test  for  Occult  Blood     .      .      .      .      .      .  124 

The  Demonstration  of  Ferments  in  the  Feces .  125 

Trypsin 125 

The  Plate  Test  of  Muller-Schlecht 125 

The  Casein  Method  of  Gross 125 

Steapsin 125 

Grutzner-Gamgee  Test 126 

von  Oefele  Test 126 

The  Nuclei  Test  of  Adolf  Schmidt 126 

Diastase  Test  (Wohlgemuth) 127 

Fat  Digestion  Tests 127 

Carmin  or  Charcoal  Test 128 

Sahli's  Glutoid  Capsule  Test 129 

Einhorn's  Bead  Test 129 

The  Test-diet  Stool  Findings  in  Gastric  and  Intestinal  Affections  .      .      .  131 

Achyha  Gastrica  and  Subacidity 131 

Hyperacidity 131 

Gastric  Ulcer  and  Gastric  Carcinoma 131 

Chronic  Catarrh  of  the  Small  Intestine 131 

Chronic  Catarrh  of  the  Large  Intestine 132 

Dysentery 133 

Intestinal  Tuberculosis 133 

Duodena]  Ulcer 133 

Enteritis  Membranacea 133 

Atonic  Constipation 133 

Spastic  Constipation 134 


14  CONTENTS 

The  Test-diet  Stool  Findings  in  Gastric  and  Intestinal  Affections — 

Intestinal  Fermentation  Dyspepsia 134 

Nervous  Diarrhea 134 

Stenosis  and  Intestinal  Carcinoma 134 


CHAPTER  V. 

Roentgen-ray  Examination. 

Technic  for  Roentgenograph^  Examination    .                  •.  135 

Roentgen  Fluoroscopy 136 

Examination  of  the  Esophagus 136 

Spasm  of  the  Esophagus 137 

Cardiospasm 137 

Diverticulum  of  the  Esophagus .      .      .     ..  138 

Deep7seated  Diverticula 138 

Carcinoma  of  the  Esophagus 138 

Examination  of  the  Stomach 138 

Gastroptosis 139 

Tonus       .      .      .      .      : 140 

Motility 140 

Atony .140 

Dilatation 140 

Gastric  Ulcer 141 

Callous  Ulcer 141 

Perforating  Ulcer  (Haudek's  niche) 141 

Hour-glass  Stomach 142 

Carcinoma 142 

Pyloric  Obstruction                         . 142 

Examination  of  the  Intestine 143 

Duodenal  Ulcer 143 

Normal  Duodenal  Cap 143 

Ileal  Stasis 144 

Colon 144 

Normal  Motility I45 

Position 145 

Deviation 146 

Constipation  and  Colonic  Stasis 146 

Cecum  Mobile .      .  146 

Vermiform  Appendix 146 

Colonic  Stasis      . 147 

Sigmoid  Flexure 148 

Diverticulitis 14° 

Hirschsprung's  Disease 148 

Stenosis " I48 

Multiple  Diverticula 149 

Carcinoma  of  the  Rectum 149 

Diagnosis  of  Postoperative  Obstructions        ........  149 

Pancreas I4" 

Liver 149 

Gall  Bladder 149 

Gallstones 150 


CONTENTS  1 5 

Examination  of  the  Intestine — 

Spleen 150 

Peritonea]  Inflation       ' 150 


CHAPTER  VI. 

Diet  in  Gastric  Diseases. 

Heat  Value  of  Foods 151 

Dietary  Regulations  and  Lists 152 

Composition  of  Common  American  Foods 153 

Protein,  Fat,  Carbohydrates,  Calories 153 

Vitamin 157 

Solubilities  of  Vitamins 158 

Stability  of  Vitamins 159 

Meat 159 

Gelatin 161 

Beef  Tea 161 

Eggs '. 161 

Fat i 162 

Milk 162 

Karell  Cure 162 

Buttermilk 164 

Whey 164 

Koumiss 164 

Kefir 164 

Yoghurt 164 

Bulgarian  Lactic  Acid  Bacilli   .    • 165 

Cheese 165 

Bread 165 

Gruel  Soups 166 

Potatoes ' 166 

Rice 166 

Green  Vegetables      • 167 

Legumes 167 

Fruit 167 

Sugar 167 

Spices 167 

Water 168 

Alcohol 168 

Tea  and  Coffee 169 

Cocoa 169 

Tobacco 169 

Instructing  the  Patient 169 


CHAPTER  VII. 

Diet  in  Intestinal  Diseases. 

Regulation  of  the  Diet ■      172 

Constipating  Diet 172 


16  CONTENTS 

Diagnosis  by  Examination  of  Feces      .  173 

Fermentation  ....... 173 

Putrefaction     . 173 

Antiseptic  Food 174 

Antiputrefactive  Diet ' 174 

.    Milk 175 

Salicylic  Milk 176 

Gelatin 177 

Whortleberries  and  Blackberries 177 

Antibacterial  Soups 178 

Jellies 178 

Green  Vegetables     ..-..' 179 

Beverages 180 

Antifermentative  Diet 181 

Protein-fat 181 

Watery  Soups 182 

Chicken,  Squab,  Eggs,  Noodles,  Zwieback,  Toast 182 

Laxative  Diet 182 

Cellulose  Digestion 183 

Indigestible  Residues ' 184 

Graham  Bread,  Rye  Bread,  etc 184 

Agar 184 

Raw  and  Cooked  Fruit 185 


CHAPTER  VIII. 

Artificial  Food  Preparations. 

Preparations  of  Animal  Protein '. 187 

Somatose 187 

Carringen 188 

Tropon '. 188 

Salvatose _ 188 

Fersan ' 188 

Peptones 188 

Preparations  from  Vegetable  Protein .  191 

Roborat 191 

Aleuronat  Flour -.  191 

Mutase     . 191 

Preparations  from  Milk  Protein       .  " 191 

Nutrose 191 

Eucasin 192 

Sanatogen 192 

Plasmon *" 192 

Milk  Somatose .      .  192 

Globon 192 

Galactogen .  192 

Mammala 192 

Nutritive  Substances  from  Egg  Protein 192 

Nutritive-Heyden 192 

Protogen  . .192 


CONTENTS  17 

Preparations  from  Carbohydrates •     •  192 

Finely  Divided  Flours 193 

Dextrinated  Flours 193 

Malt  Extract L93 

Malt  Soup 193 

Maltose  Buttermilk 193 

Maltine 193 

Mixed  Nutritive  Preparations 193 

Bygiama 193 

Odda 193 

Protein-milk-salt-cocoa 193 

Racahout 194 

Acorn-cocoa 194 

Preparations  Containing  Fat 194 

Russell's  Emulsion 194 

Nutrole 194 

Sevetol ". 194 

Cod-liver  Oil 194 

Oil  of  Sesame       .      .      .      .    ' 194 

Lipanin 194 

Kraft  Chocolate 194 

Milk  Preparations 194 

Vegetable  Milk 194 

Cream  Protein  Mixture 194 

Fat  Milks 194 

Kefir  and  Koumiss 194 

Stimulating  Preparations 194 

Meat  Extract 194 

Beef  Tea 194 

Meat  Juice 194 

Essence  of  Beef 195 

Fluid  Meat 195 

Bovril 195 

Karno 195 

Composition  and  Relative  Values  of  Meat  Extracts 195 

CHAPTER   IX. 

Lavage  of  the  Stomach. 

Indications 197 

Contra-indications 198 

Apparatus 199 

Technic :      ...  199 

Stomach  Tube  and  Funnel 200 

Autolavage 201 

Suction  Bulb  (Friedlieb) 203 

Suction  Tube  (Strauss) 204 

The  Stomach  Douche 205 

Perforated  Tube  (Rosenheim) 205 

Richter's  Method 205 

Einhorn's  Apparatus 206 

Turck's  Double-flow  Tube 206 

Stomach  Tube  (Chase) 207 

2 


IS  CONTENTS 

CHAPTER   X. 

Massage — Electricity. 
Massage  of  the  Stomach — 

Indications 208 

Contra-indications ' .      .         '               .  208 

Technic 208 

Tapotement 209 

Petrissage 210 

Crede's  Method 210 

Vibratory  Massage 210 

Intestinal  Massage 211 

Technic 211 

Rotating  Effleurage 212 

Deep  Klneading 212 

Rotating  Petrissage 213 

Tapotement 213 

Chronic  Constipation 214 

Vibrating  Massage ' .      .  214 

Electric  Treatment 214 

Indications 215 

Intraventricular  Electrization 216 

Stomach  Electrode  (Boas) 216 

Stomach  Electrode  (Wegele) 217 

Intragastric  Electrode  (Einhornj 217 

Combined  Stomach  Tube  and  Electrode  (Stockton)    .      .      .      .218 

Extraventricular  Electrization 219 

The  Sinusoidal  Current     . 219 


CHAPTER  XL 

Treatment  of  Diseases  of  the  Intestine  through  the  Rectum. 

Cleansing  Enemata 220 

Technic 220 

Rectal  Tube 221 

Glycerin  Enemata 222 

Glycerin  Suppositories 223 

Oil  Enemata 223 

Oil  Enemator  (Zweig) 224 

Oil  Enemator  (Roberts) 225 

Paraffin  Enemata 225 

Carbon  Dioxid • 226 

Bile  Enemata 226 

Cathartics 227 

Chloroform-water  Irrigations 227 

Air  Insufflation 228 

Intestinal  Douche 228 

Mechanical  Treatment 228 

Swedish  Manipulation 228 

Rectal  Massage 229 


CONTENTS  19 

Mechanical  Treatment — 

Rectal  Tampons 230 

Proctoscope  (Kelly) 230 

Rectal  Electrodes 230 

Treatment  of  Intestinal  Irritation 232 

Irrigation  of  the  Intestine 232 

Technic 232 

Irrigation  Tube  (Zweig) 233 

Irrigation  Apparatus  (Rosenberg) 234 

Irrigation  Tube  (Wolbarst) 235 

Antiseptic  Irrigations 235 

Sedative  Irrigations 236 

Astringent  Irrigations 236 

Krameria  in  Rectal  Catarrh 236 

Natural  Mineral  Waters 237 

Dry  Treatment 237 

Pneumatic  Sigmoidoscope  (Strauss) 237 

Introduction  of  Sigmoidoscope 238 

Powder  Blower  (Rosenberg) 238 

Proctoclysis 239 

Apparatus 239 

Heating  Chamber  for  Electric  Unit  (Elbrecht) 240 

Self-retaining  Rectal  Tips 240 

Electric  Heating  Unit 241 

Electric  Heater  in  Operation 242 

Heat  Unit  for  Alcohol  or  Bunsen  Flame 242 

Alcohol  or  Gas  Heater  (Elbrecht) .  243 

Glass  Attachment  for  Proctoclysis 244 

Thermos  Proctoclysis  Apparatus 245 

Nutrient  Enemata 245 

Technic 245 

Variety     .      .      . 245 

CHAPTER  XII'. 

Hydrothekapetjtics — Mineral  Waters. 

Hydriatic  and  Thermic  Treatment 247 

Wet  Rub 247 

Half  Baths 248 

'  Cold  Entire  Pack 248 

Warm  Entire  Pack 249 

Prolonged  Baths       .      . 249 

Oxygen  and  Carbon  Dioxid  Baths 249 

Indications  for  Hydrotherapeutic  Treatment 249 

Compresses 250 

Mashed-potato  Poultice 250 

Linseed  Meal  Poultice 250 

Priessnitz  Bandage 250 

Leiter  Cooling  Apparatus 251 

Douches 251 

Mineral  Waters 252 


20  CONTENTS 

Mineral  Waters — 

Classification : 252 

Alkaline  Chlorin  Waters 252 

Sodium  Chlorid  Waters .      .  253 

Alkaline  Carbonated  Waters 253 

Ferruginous  Waters 254 

Bitter  Waters 254 

Drinking  Cures 254 

Purgative  Waters 254 

Constipating  Waters 256 

Mineral  Baths 256 

Sea  Baths 256 

Climatic  Cures 256 


CHAPTER  XIII. 

Medication  in  Gastric  Diseases. 

Hydrochloric  Acid  and  Pepsin 258 

The  Double  Capsule  Method  of  Administering  Hydrochloric  Acid       .      .  260 

Acidol 260 

Gasterin 262 

Dyspeptine " 262 

Pancreatin .  262 

Pankreon 263 

Papayotin 263 

Pineapple  Juice 263 

Diastase 262 

Alkalis •.....' 263 

Alkaline  Earths " 264 

Alkaline  Carbonates 264 

Bismuth 265 

Strychnin  and  the  Bitters .  266 

Alcohol 267 

Condurango  Bark .'....  267 

Orexin 237 

Silver  Nitrate .      .    - 237 

Gastric  Sedatives 238 

Amyl  Nitrite 268 

Nitroglycerin *  . 239 

Chloral  Hydrate 269 

Bromids 269 

Dilute  Hydrocyanic  Acid    . 269 

Cannabis  Indica 239 

Cocain  Hydrochlorid 269 

Gastric  Anodynes 270 

Chloroform ' 270 

Orthoform-new 270 

Anesthesin 270 

Drugs  Used  Incidentally  in  Gastric  Disorders 271 

Atropin 271 

Pilocarpin 271 


(<>,X  TENTS  2] 

Drugs  Used  Incidentally  in  Gastric  Disorders — 

Nicotin 271 

Eumydrin 271 

Kpinephrin 271 

Antiseptics 272 

Resorcinol 272 

Phenol 272 

Salicylates 272 

Iodin 272 

Hydrogen  Pcroxid 272 

Magnesium  Peroxid 273 

Emollients 273 

OUve  Oil 273 

CHAPTER  XIV. 

Medication  in  Intestinal  Diseases. 

Intestinal  Sedatives 274 

Narcotics 274 

Opium 274 

Pantopon 275 

Papaverin 275 

Benzyl  Benzoate 276 

Uzara 276 

Astringents 276 

Tannic  Acid 277 

Tannalbin 277 

Tannocol 277 

Tannyl 277 

Milksomatose 277 

Tannigen 277 

Tannoform 278 

Agar-tannin 278 

Gambir 278 

Krameria 278 

Kino 278 

Quercus  Alba 278 

Hematoxylon 278 

Salts  of  Metals 279 

Protectives 279 

Calcium  Preparations 279 

Kaolin  (bolus  alba) 279 

Antiseptics  and  Antifermentatives •    '.      .      .  279 

Salicylic  Acid 280 

Calomel 280 

Magnesium  Peroxid 280 

Hydrogen  Peroxid 280 

Peroxid  Agar 280 

Benzonaphthol 281 

Ichthyol '.....  281 

Creosote 281 


22  CONTENTS 

Intestinal  Sedatives — 

Antiseptics  and  Antifermentatives — 

Thiocol 281 

Enteral 281 

Nosophen 281 

Menthol 281 

Resorcinol 281 

Saccharin 281 

Yeast 281 

Purgatives 282 

Indications  for  the  Administration  of  Purgatives 282 

Opium  in  Purgation 283 

Benzyl  Benzoate  in  Intestinal  Spasm 284 

Combinations 287 


CHAPTER  XV. 

Diseases  of  the  Mouth. 

Anatomy  of  the  Mouth 289 

Oral  Sepsis 290 

Focal  Infection 290 

General  Treatment  of  the  Diseases  of  the  Mouth 293 

Oral  Affections  in  General  Intoxications 299 

From  Metals 299 

Mercury       .      . 299 

Bismuth .  300 

Lead 301 

Silver 301 

From  Metalloids 301 

Phosphorus 301 

Bromids 301 

Iodids 301 

Medicinal  Exanthema 301 

Affections  of  the  Mouth  in  Constitutional  Infectious  Diseases  (measles, 
scarlet  fever,  rubeola,  varicella,  variola,  vaccinia,  typhoid  and  para- 
typhoid fevers,  foot-and-mouth  disease,  influenza) 302 

Diseases  of  the  Mouth  in  Non-infectious  Constitutional  Diseases  (hemo- 
philia, chlorosis,  purpura,  scorbutus,  infantile  scurvy,  diabetes,  gout)  302 

Erosions  and  Burns  of  the  Mouth 303 

Erosions 303 

Treatment 303 

Burns        . 304 

Lesions  of  the  Oral  Mucosa        .           304 

Traumatic  Lesions 304 

Treatment - 304 

Thickening  of  Epithelium 304 

Palatal  Ulcers 304 

Treatment 304 

Lingual  Ulcers 305 

Treatment 305 

Traumatic  Tumors 305 

Treatment 305 


CONTENTS  23 

Stomatitis ;j05 

Simple  or  Catarrhal  Stomatitis 305 

Treatment 305 

Gangrenous  Stomatitis 305 

Treatment 306 

Noma 306 

Treatment 307 

Erysipelatous  Stomatitis 307 

Treatment 307 

Aphthae 307 

Treatment 308 

Chronic  Aphthae  (Aphthae  Tropica*) 308 

Sprue 308 

Thrush 309 

Treatment 309 

Syphilis  of  the  Mouth 309 

Primary  Syphilis 309 

Treatment 310 

Secondary  Syphilis 310 

Treatment 311 

Tertiary  Syphilis 311 

Treatment 312 

Tuberculosis  of  the  Mouth 312 

Lupus  of  the  Oral  Mucosa 312 

Treatment 313 

Glanders  of  the  Mouth 313 

Treatment 314 

Leprosy  of  the  Mouth 314 

Treatment 315 

Scleroma 315 

Treatment 315 

Actinomycosis 316 

Treatment 316 

Skin  Diseases  in  the  Mouth 316 

Eczema 317 

Treatment 317 

Lichen  Planus 317 

Treatment 317 

Lupus  Erythematosus 317 

Treatment 317 

Pemphigus 317 

Treatment 318 

Erythema  Exudativum  Multiforme .      .      .      .318 

Herpes 318 

Urticaria 318 

Scleroderma 318 

Leukoplakia 319 

Symptoms 319 

Treatment 319 

Animal  Parasites  in  the  Mouth 320 

Nervous  Affections  of  the  Mouth 320 

Paralysis  of  the  Facial  Nerve 320 


24  CONTENTS 

Nervous  Affections  of  the  Mouth — 
Paralysis  of  the  Facial  Nerve — 

Treatment 321 

Glossodynia 321 

Treatment 321 

Vasomotor,  Trophic  and  Secretory  Disorders 321 

Affections  of  the  Tongue 322 

Malformation 322 

Coating  or  Furring 322 

Treatment .  322 

Lingua  Geographica 323 

Treatment 323 

Hair-tongue  (Lingua  Nigra) .      .      .      .      .      .  323 

Treatment 323 

Phlegmonous  Processes  of  the  Tongue 324 

Abscess 324 

Treatment 324 

Acute  Diffused  Glossitis 324 

Treatment 324 

Decubital  Ulcer  of  the  Tongue 325 

Treatment 325 

Chronic  Superficial  Glossitis 325 

Treatment   .      . 325 

Acute  Papular  Glossitis       .      .      .      .      .      .      .      .      .      .      .      .      .  325 

Treatment 326 

Macroglossia 326 

Lingua  Plicata 326 

Affections  of  the  Lingual  Tonsil 326 

Acute  Lingual  Tonsillitis 326 

Hypertrophy  of  the  Lingual  Tonsil 326 

Treatment 326 

Hyperkeratosis 327 

Treatment 327 

Diseases  of  the  Salivary  Ducts 327 

Sialodochitis 327 

Sialoliths        327 

Symptoms 328 

Treatment 328 

Diseases  of  the  Salivary  Glands 328 

Secondary  Sialadenitis  in  Affections  of  the  Salivary  Ducts      .      .      .  328 

Treatment 328 

Diseases  of  the  Salivary  Glands  in  General  Affections 329 

Actinomycosis,  Syphilis,  Tuberculosis      . 329 

Epidemic  Parotitis 329 

Treatment 329 

Chronic  Enlargement  of  the  Salivary  and  Lacrimal  Glands  (Miku- 
licz's Disease) 330 

Treatment 330 

Ptyalism .-  330 

Aptyalism • 330 

Phlegmons  of  the  Buccal  Glands 330 

Ludwig's  Angina 330 


CONTEXTS  25 

Phlegmons  of  the  Buccal  Glands — 
Ludwig'a  Angina — ■ 

Treatment 331 

Affections  of  the  Alveolar  Processes 33 1 

Parulis  (Periostitis  Alveolaris  Dcntalis) 331 

Treatment 332 

Pyorrhea  Alveolaris 332 

Treatment 332 

Gingivitis 333 

Affections  of  the  Lips  and  Cheeks 333 

Congenital  Fistula?  of  the  Lower  Lip 333 

Acute  Cheilitis 334 

Treatment 334 

Chronic  Cheilitis 334 

Cheilitis  Glandularis 334 

Cheilitis  Exfoliativa 334 

Affections  of  the  Malar  Mucosa 335 

Benign  Tumors  of  the  Mouth 335 

Fibroma 335 

Treatment 335 

Lipoma 335 

Treatment 336 

Myxoma        336 

Myoma 336 

Chondroma,  Osteoma 336 

Hemangioma 336 

Cavernous  Angiomata .  336 

Treatment 336 

Racemose  Aneurysm 336 

Lymphangioma 337 

Diffuse  Lymphoma .  337 

Treatment   .      .     ' 337 

Dermoid  Cysts 337 

Treatment 338 

Cysts  Originating  from  Glands .  338 

Treatment 338 

Ranula 339 

Treatment 339 

Cysts  at  the  Root  of  the  Tongue 339 

Struma  of  the  Lingual  Base 339 

Treatment 340 

Adenoma 340 

Papilloma       .      .  ■ 340 

Treatment 340 

Endothelioma 340 

Treatment 341 

Malignant  Tumors  of  the  Mouth 341 

Sarcoma 341 

Treatment 342 

Carcinoma 342 

Carcinoma  of  the  Lips 342 

Treatment 342 


26  CONTENTS 

Malignant  Tumors  of  the  Mouth — 
Carcinoma — ■ 

Carcinoma  of  the  Tongue 343 

Treatment 344 

Carcinoma  of  the  Buccal  Fundus 344 

Carcinoma  of  the  Malar  Mucosa       .      .      .      .* 344 

Treatment 344 

Carcinoma  of  the  Palate 344 

Treatment 344 

Carcinoma  of  the  Uvula 344 

Tumors  of  the  Maxillae 345 

Fibroma 345 

Chondroma 345 

Osteoma 345 

Odontoma 345 

Cysts 345 

Adamantoma 345 

Sarcoma 346 

Chondrosarcoma  and  Myxosarcoma 346 

Carcinoma 346 

Affections  of  the  Pharynx 346 

Acute  and  Chronic  Pharyngitis 346 

Treatment 347 

Follicular  Tonsillits 347 

Treatment 347 

Parenchymatous  Toinsillitis,  Suppurative  Tonsillitis,  or  Quinsy  .      .  347 

Treatment 347 

Chronic  Tonsillitis 347 

Hypertrophy  of  the  Tonsils      . 347 

Retropharyngeal  Abscess 348 

Treatment  .     .     .     . 348 

Tuberculous  Abscess 348 


CHAPTER  XVI. 

Diseases  of  the  Esophagus. 

Anatomy  of  the  Esophagus 349 

Deglutition  Sounds 350 

Instrumental  Examination 350 

Esophageal  Bougie 350 

Esophagoscope  and  Gastroscope 351 

Inflammation  of  the  Esophagus .  353 

Acute  Esophagitis 353 

Symptoms 353 

Treatment 353 

Chronic  Esophagitis 353 

Symptoms 354 

Treatment 354 

Esophageal  Syringe  (Rosenheim) 354 

Exfoliative  Esophagitis 355 


CONTENTS  27 

Inflammation  of  the  Esophagus — 
Exfoliative  Esophagitis — 

Treatmenl 355 

Fibrinous  Esophagitis 

Treatment 355 

Phlegmonous  Esophagitis 356 

Treatment 356 

Infectious  Diseases  in  the  Esophagus    . 356 

Diphtheria 356 

Variola 357 

Skin  Diseases  in  the  Esophagus 357 

Pemphigus  and  Herpes  Zoster 357 

Burns  and  Corrosions  of  the  Esophagus 357 

Treatment * 358 

Ulcers  of  the  Esophagus 358 

Gangrenous  Ulcers 358 

Decubital  Ulcers 358 

Tubercular  Ulcers 359 

Treatment _ 359 

Syphilitic  Ulcers 359 

Diagnosis 360 

Treatment .360 

Peptic  Ulcer 360 

Symptoms 360 

Treatment 360 

^Vegetable  and  Animal  Parasites 361 

Actinomycosis .  361 

Thrush 361 

Animal  Parasites 361 

Stricture  of  the  Esophagus 361 

Neoplasms  in  the  Esophagus 362 

Papilloma     .            362 

Fibroma 362 

Other  Benign  Neoplasms 362 

Carcinoma 362 

Symptoms 363 

Diagnosis 363 

Sarcoma 364 

Cicatricial  Stricture 364 

Treatment  of  Esophageal  Stricture 364 

Technic  of  Introducing  the  Sound 365 

Olive-pointed  Sound  in  Esophagus 365 

Esophageal  Sound  (Crawcour) 367 

Dilating  the  Stricture 368 

Esophageal  Dilators  (Sippy,  Senator,  Schreiber) 370 

Esophageal  Bougie  and  Cannula  (Leyden  and  RenversJ  .      .      .371 

Surgical  Treatment 372 

Alimentation 372 

Symptomatic  Treatment 373 

Diverticula  of  the  Esophagus 374 

Traction  Diverticula 374 

Treatment 3.4 


28  CONTENTS 

Diverticula  of  the  Esophagus — 

Pulsion  Diverticula 374 

Symptoms ' 375 

Diagnosis 375 

Prognosis 375 

Treatment .  376 

Diverticular  Sounds  (Leube  and  Starck) 376 

Foreign  Bodies  in  the  Esophagus 377 

Other  Causes  of  Esophageal  Stricture • 378 

Thrush 378 

Compression  of  the  Esophagus      .  378 

Spasm  of  the  Esophagus 378 

Symptoms •  .  378 

Treatment 379 

Dilatation  of  the  Esophagus 380 

Etiology ......  380 

Symptoms 380 

Diagnosis 381 

Prognosis 381 

Treatment 381 

Congenital  Dilatation 382 

Congenital  Stricture 383 

Rupture,  Malacia,  Perforation,  Hemorrhage 383 

Neuroses  of  the  Esophagus 384 

Hyperesthesia ; 384 

Treatment   .... 385 

Anesthesia 385 

Paralysis 385 

Symptoms ,  •  385 

Treatment 386 

Atony 386 

Treatment 386 


CHAPTER  XVII. 

Motor  Neuroses. 

Vagotonia;  Sympathicotonia;  Hypermotility;   Peristaltic   Unrest;   Cardiospasm; 

Pylorospasm;  Eructations;  Pneumatosis;  Vomiting;  Rumination; 

Regurgitation;  Pyloric  Insufficiency;  Singultus  Gastricus. 

The  Vegetative  Nervous  System -  .  387 

Vagotonia  and  Sympathicotonia      . 388 

Diagnostic  Phenomena  in  Disturbances  of  the  Vegetative  Nervous  System  390 

Aschner's  Phenomenon ' 390 

Hering's  Phenomenon 390 

The  Pilocarpin  Test 391 

Differential  Tables 391 

Treatment 391 

Hypermotility  (Hyperkinesis) 392 

Peristaltic  Unrest  of  the  Stomach 392 

Treatment 392 


CONTENTS  29 

Cardiospasm 392 

Symptoms 394 

Diagnosis :',\)\ 

Delineator  String 394 

Prognosis 395 

Treatment 396 

Oil  Cure 397 

Mechanical  Treatment 397 

Electrotherapy 398 

Myer'a  Cardia  Dilator 398 

Surgical  Treatment 398 

Pylorospasm 398 

Treatment 400 

Technic  of  Dilating  the  Pylorus 400 

Nervous  Eructation  (Aerophagy) 401 

Diagnosis 402 

Treatment 402 

Pneumatosis  (Drum-belly) 403 

Treatment 403 

Nervous  Vomiting 403 

Gastric  Crises 403 

Treatment 404 

Rumination  (Merycism) 405 

Treatment 406 

Regurgitation 406 

Insufficiency  of  the  Pylorus 407 

Treatment 407 

Singultus  Gastricus  (Hiccough) 408 

Treatment «.      .  408 


CHAPTER  XVIII. 
Sensory  Neuroses. 

Gastralgia;  Hyperesthesia;  Gastralgokenosis;  Nausea;  Bulimia;  Akoria; 

Anorexia. 

Gastralgia 410 

Treatment .410 

Gastric  Hyperesthesia 413 

Treatment 413 

Gastralgokenosis  (Stomach-ache) 414 

Treatment 414 

Nervous  Nausea 415 

Treatment 415 

Bulimia 416 

Treatment 416 

Akoria 416 

Treatment 416 

Nervous  Anorexia 416 

Treatment 417 


30  CONTENTS 


CHAPTER  XIX. 

Nervous  Dyspepsia — Neurasthenia  Gastrica. 

Etiology 418 

Eye-strain 418 

Cholecystitis,  Constipation,  etc 419 

Appendicitis -. 419 

Symptoms 419 

Prognosis 420 

Prophylaxis .  420 

Treatment 421 

Lactovegetable  Diet 422 

Physical  Treatment 423 

Sea-water  Therapy 423 

Apparatus  for  the  Injection  of  Sea-water 424 

Drug  Treatment 425 

Surgical  Treatment 427 

Umbilical  Dyspepsia 428 

Treatment 428 

CHAPTER  XX. 

Secretory  Neuroses. 
Hyperchlorhydria — Hyperacidity — Superacidity . 

Etiology  of  Hyperchlorhydria 430 

Pathology 431 

Symptoms-? 431 

Diagnosis 431 

Prognosis 432 

Treatment 432 

Hygienic 432 

Dietetic 432 

Medicinal 435 

Astringents 435 

Atropin 435 

Alkaloids 436 

Hydrogen  Peroxid 436 

Analgesics 436 

Acids       ..." 436 

Alkalis 436 

Course  of  Medication  . 437 

Lavage  of  the  Stomach 438 

CHAPTER  XXI. 

Secretory  Neuroses  (Continued). 

Hypersecretion — Gastrorrhea — Gastrosuccorrhea — Gastrochylorrhea. 

Intermittent  or  Periodic  Hypersecretion  (Acute  Intermittent  Gastrorrhea)  440 

Etiology 440 


CONTENTS  31 

Intermittent  or  Periodic  Hypersecretion  (Acute  Intennil  t  ■  -i i !  ( ;astn>rrhe:i  i 

Symptoms 440 

Diagnosis 441 

Treatment 441 

Continuous  Hypersecretion  (Chronic  Gastrorrhea) 441 

Etiology 442 

Symptoms 442 

Diagnosis 443 

External  Examination  of  the  Stomach 443 

Prognosis "...  443 

Treatment 443 

Diet 444 

Medicinal  Treatment 445 

Lavage  of  the  Stomach 446 

Mineral  Waters 447 

Physical  Treatment •     .      .      .  447 

Surgical  Treatment 447 

Alimentary  Hypersecretion         447 

Symptoms 447 

Diagnosis 447 

Treatment 448 

Medicinal  Treatment ■ 448 

Lavage  of  the  Stomach 448 


CHAPTER  XXII. 

Acute  Gastritis:    Simple;  Infectious;  Toxic;  Phlegmonous. 

Simple  Acute  Gastritis 449 

Etiology 449 

Pathology      .      .      .    ' 449 

Symptoms 450 

Course 450 

Prophylaxis 450 

Treatment 450 

Lavage 451 

Emetics 451 

Medication 451 

Diet 452 

Acute  Infectious  Gastritis 453 

Etiology 453 

Pathology *      .......  453 

Symptoms 454 

Treatment 454 

Toxic  Gastritis 455 

Etiology 455 

Pathology 455 

Symptoms ; 456 

Prognosis 456 

Treatment      . 456 

Phlegmonous  Gastritis 457 


32  CONTENTS 

Phlegmonous  Gastritis — 

Etiology 457 

Pathology .  458 

Symptoms  and  Course "  .  458 

Treatment 459 


CHAPTER  XXIII. 

Chronic  Gastritis — Acid  Gastritis — Subacid  Gastritis — Anacid 
Gastritis;  Achylia  Gastrica. 

Chronic  Gastritis        .  460 

Etiology .'....  460 

Pathology 461 

Symptoms .  461 

Objective  Symptoms 462 

Diagnosis 462 

Prognosis 463 

Achylia  Gastrica 464 

Etiology 465 

Pathology 465 

Symptoms 465 

Treatment  of  Chrome  Gastritis  and  Achylia  Gastrica 466 

Diet 466 

Medicinal  Treatment 469 

Hydrochloric  Acid 469 

Papain 469 

Pancreatin 469 

Stomachics ' 469 

Treatment  by  Gastric  Lavage 471 

Treatment  with  Mineral  Waters 472 

Physical  Treatment '  472 


CHAPTER  XXIV. 

Motor  Insufficiency. 

Atony  (Myasthenia) ;  Dilatation  (Ischochymia,  Gastrectasis) ;  Pyloric  Stenosis; 
Acute  Dilatation  of  the  Stomach. 

Motor  Insufficiency  of  the  First  Degree  (Atony) 473 

Etiology .473 

Symptoms 474 

Diagnosis  .      .     • " 474 

Treatment 475 

Diet  in  Normal  Acidity,  Hyperacidity  and  Hypersecretion    .      .  475 

Diet  in  Subacidity  and  Anacidity 476 

Lavage  of  the  Stomach 476 

Medicinal  Treatment .      .  •    .      .      .  477 

Physical  Treatment 477 

Treatment  with  Mineral  Waters 477 


CONTENTS  33 

Motor  Insufficiency  of  the  Second  Degree  (Dilatation) 478 

Etiology 478 

Symptoms 479 

Diagnosis 480 

Treatment 481 

To  Allay  Thirst 481 

Rectal  Alimentation 482 

Subcutaneous  Nutrition 482 

Treatment  by  Lavage 482 

Mechanical  Treatment 483 

Physical  Treatment 483 

Mineral  Waters 483 

Medicinal  Treatment 483 

Treatment  of  Stenosis  of  the  Pylorus 484 

Dilatation 485 

The  Einhora  Pyloric  Dilator 485 

Surgical  Treatment 485 

Gastric  Tetany          485 

Acute  Dilatation  of  the  Stomach 486 

Treatment 486 


CHAPTER  XXV. 

Gastric  Ulcer. 
Ulcus  Ventriculi — Round  Ulcer — Peptic  Ulcer — Perforating  Gastric  Ulcer. 

Pathology  of  Gastric  Ulcer 488 

Etiology 489 

Frequency " 489 

Sex  Predisposition  and  Age 489 

Symptoms       .      .      .      .  • 490 

Localization  of  Pain 491 

Vomiting 491 

Hemorrhage 491 

Perforation 492 

Appetite 492 

Complications  and  Sequelae 493 

Diagnosis 493 

Einhorn's  "String  Test" 493 

Roentgenography  in  the  Diagnosis 494 

Prognosis 494 

Treatment 495 

Prophylaxis 495 

Leube-Ziemssen  Treatment 495 

Lenhartz  Treatment 498 

Sippy  Treatment .  499 

Einhorn's  Duodenal  Alimentation 500 

Method  of  Procedure 501 

Morgan's  Modification 502 

Medicinal  Treatment 503 

Alkaline  Formulae 503 

3 


34  CONTENTS 

Treatment — 

Medicinal  Treatment — 

Bismuth  Salts 504 

Silver  Nitrate 505 

Scarlet  Red 50.5 

Tincture  of  Iodin 506 

Olive  Oil 506 

Treatment  by  Antilytic  Serum 506 

Treatment  by  Bacterial  Vaccines        506 

Surgical  Intervention 507 

Perforation  in  Gastric  Ulcer .  509 

Subphrenic  Abscess .      .     ,.      .      .      .  509 

Pyloric  Stenosis 509 

Hypertrophic  Stenosis  of  the  Pylorus 509 

Rammstedt  Operation .510 


CHAPTER  XXVI. 

Gastric  and  Intestinal  Hemorrhage. 

Diagnosis 511 

Differential 512 

Prophylaxis 512 

Treatment 512 

Lavage 513 

Enemata 514 

Hemostatics 514 

Analgesics 518 

Operative  Treatment     .  520 


CHAPTER  XXVII. 

Erosions;  Perigastritis. 

Erosions  of  the  Stomach       .  521 

Forms 521 

Etiology 521 

Symptoms      . 522 

Diagnosis 522 

Pathology 522 

Prognosis 523 

Treatment 523 

General  Treatment      ........     f 523 

Local  Treatment - 523 

Perigastritis 524 

Hour-glass  Contraction 524 

Symptoms 525 

Forms 525 

Diagnosis 525 

Treatment 526 


co.xtk.xts  :;:. 


CHAPTER  XXVIII. 

Arteriosclerosis;  Syphilis;  Tuberculosis. 

Arteriosclerosis 528 

Etiology 528 

Tathology 529 

Symptoms 529 

Diagnosis 530 

Treatment 530 

Syphilis  of  the  Stomach 533 

Diagnosis 533 

Treatment 534 

Tuberculosis  of  the  Stomach 536 

Forms 536 

Treatment •.      .      .  536 


CHAPTER  XXIX. 

Tumors  of  the  Stomach. 

Carcinoma;  Sarcoma;  Fibroma;  Fibromyoma;  Lipoma;  Adenoma;  Papil- 
loma; Polypi;  Hernia  Epigaslrica. 

Carcinoma 537 

Incidence 537 

Etiology .  537 

Pathology 539 

Forms 540 

Medullary  Carcinoma 540 

Adenocarcinoma 540 

Gelatinous  or  Colloid  Carcinoma 540 

Scirrhous  Carcinoma 540 

Ulcerocarcinoma 541 

Complications - 541 

Symptoms "...  541 

Diagnosis 542 

Hemolytic  Reactions 543 

Antitryptic  Reaction 544 

The  Miostagmin  Reaction 544 

The  Abderhalden  Reaction 545 

Blood-sugar  Tolerance  Test 544 

Linitis  Plastica  Hypertrophica 546 

Treatment "...  546 

Internal  Treatment 546 

Physical  Treatment 549 

Medicinal  Treatment 549 

Radiation  Treatment " 550 

Treatment  of  Carcinoma  of  the  Cardia 551 

Sarcoma 553 

Etiology 553 

Pathology 553 


36  CONTENTS 

Sarcoma — 

Symptoms 553 

Diagnosis 554 

Treatment : 554 

Benign  Tumors 555 

Hernia  Epigastrica 555 

CHAPTER  XXX. 

Gastroentero  PTOSIS . 

Gastroptosis;  Enteroptosis;  Splanchnoptosis;  Coloptosis;  Nephroptosis; 
Hepatoptosis;  Splenoptosis;  Cecum  Mobile;  Redundant  Sigmoid. 

Etiology  of  Gastroenteroptosis 557 

Forms 557 

Pathology .  558 

Habitus  Enteroptoticus  ■ 558 

Descent  of  Transverse  Colon 560 

Kinks  of  the  Intestine 561 

Symptoms 562 

Diagnosis 564 

Gastroenteroptosis 564 

Nephroptosis 565 

Palpation  of  Movable  Kidney 567 

Hepatoptosis 568 

Splenoptosis 569 

Prognosis  of  Gastroenteroptosis 569 

Prophylaxis 569 

Treatment .  569 

Hyperalimentation .  ' 569 

Technic  of  Nutrition 571 

Hydrotherapeutics 573 

Massage  and  Exercise 574 

Electrotherapeutics 574 

Mechanical  Treatment  of  Gastroenteroptosis 574 

Bandages 575 

Aaron's  Abdominal  Bandage 576 

Adhesive  Plaster  Bandage , 578 

Corsets 578 

Adhesive  Belt 579 

Medicinal  Treatment 581 

Surgical  Treatment 583 

CHAPTER  XXXI. 

Diseases  of  the  Liver. 

Hepatitis;  Abscess;   Yellow  Atrophy;  Febrilis  Icterus;  Hyperemia;  Cirrhosis; 

Atrophy;  Syphilis;  Tuberculosis;  Neoplasms;  Parasites;  Fatty  Liver; 

Hepatoptosis;  Neuralgia. 

Acute  Affections  of  the  Liver 584 

Acute  Inflammation  of  the  Liver        584 

Treatment 584 


CONTENTS  37 

mite  Affections  of  the  Livei — 

Abscess  of  the  Liver 584 

Symptoms ;....*..  585 

Treatment 586 

Acute  Yellow  Atrophy  of  the  Liver 586 

Treatment 587 

Febrilis  Icterus 587 

Treatment 588 

Chrome  Affections  of  the  Liver 588 

Active  Hyperemia 588 

Diagnosis 589 

Treatment 589 

Passive  Hyperemia 589 

Symptoms 589 

Treatment 590 

Atrophic  Cirrhosis 590 

Etiology 590 

Pathology 590 

Symptoms 591 

Tests  for  Lipase 592 

Levulose  Test 593 

Phthalein  Test 593 

Urobilin 593 

Prognosis 593 

Treatment 594 

General  and  Medicinal 594 

Surgical .  595 

Hj'pertrophic  Cirrhosis 596 

Etiology 596 

Symptoms 596 

Diagnosis 597 

Prognosis     .            597 

Treatment 597 

Hypertrophic  Cirrhosis  of  the  Liver  in  Bronze  Diabetes     ....  597 

Treatment 597 

Biliary  Cirrhosis 597 

Treatment 598 

Cirrhosis  Occurring  in  the  Course  of  Affections  of  the  Circulatory 

Organs 598 

Atrophy  of  the  Liver 598 

Brown  Atrophy 598 

Red  Atrophy 598 

Partial  Atrophy  .      .      . 598 

Syphilis  of  the  Liver 599 

Congenital  Syphilis 599 

Acquired  Syphilis 599 

Symptoms 599 

Diagnosis 600 

Treatment 600 

Tuberculosis  of  the  Liver 600 

Neoplasms  of  the  Liver 600 

Malignant  Formations 600 


38  CONTEXTS 

Neoplasms  of  the  Liver — 
Malignant  Formations — 

Carcinoma 600 

Sarcoma 601 

Treatment 602 

Benign  Neoplasms 602 

Fibroma 602 

Angioma 602 

Cysts 602 

Parasites  of  the  Liver 602 

Echinococci 602 

Symptoms 603 

Diagnosis 603 

Treatment 604 

Echinococcus  Multilocularis     . .  604 

Other  Parasites 604 

Fatty  Liver 604 

Etiology 604 

Pathology 605 

Treatment 605 

Hepatoptosis 605 

Treatment 605 

Neuralgia  of  the  Liver 605 

CHAPTER  XXXII. 

Diseases  of  the  Bile  Ducts  and  Gall  Bladder,. 
Cholangitis;  Cholecystitis;  Catarrhal  Jaundice;  Hemorrhage;  Neoplasms; 
Dilatation;  Parasites;  Gallstones. 

Inflammation  of  the  Bile  Ducts  and  Gall  Bladder 607 

Simple  Cholangitis  and  Cholecystitis 607 

Pathology 607 

Symptoms 608 

Diagnosis 610 

Hemocones 611 

Treatment 611 

Suppurative  Cholangitis  and  Cholecystitis 613 

Etiology 613 

Pathology 613 

Symptoms 614 

Treatment 614 

Hemorrhage  into  the  Bile  Ducts '.      .      .614 

Neoplasms  of  the  Bile  Ducts  and  Gall  Bladder 614 

Symptoms 615 

Diagnosis 615 

Treatment 615 

Dilatation  of  the  Biliary  Organs 615 

Hydrops  and  Empyema 616 

Symptoms 616 

Treatment 616 

Parasites  of  the  Bile  Ducts 616 

Diagnosis 616 

Treatment 616 


contexts  :;«.) 

Gallstones 616 

Symptoms 018 

Diagnosis 618 

Xaunyn's  Sign 619 

Murphy's  Sign 619 

Examination  of  Duodenal  Contents 619 

Treatment 619 

Anodynes  and  Narcotics 619 

Diet 620 

Medication 621 

Non-surgical  Biliary  Drainage 621 

Surgical  Treatment 622 

CHAPTER  XXXIII. 

Diseases  of  the  Pancreas. 

Pancreatitis;  Achylia;  Hemorrhage;  Necrosis;  Cysts;  Tumors;  Calculi. 

Inflammation  of  the  Pancreas 623 

Chronic  Pancreatitis 623 

Etiology 624 

Pathology 624 

Diagnosis 624 

Disturbance  of  Protein  Digestion 624 

Disturbance  of  Fat  Digestion 625 

Disturbance  of  Starch  Digestion 625 

Oil  Test  Breakfast 626 

Loewi's  Pupillary  Reaction .  626 

Cammidge  Reaction 626 

Prognosis 627 

Treatment 627 

Regulation  of  Fats,  Proteins  and  Carbohydrates        .      .      .  627 

Surgical  Treatment    .      .      .  • 628 

Acute  Pancreatitis 628 

Treatment 629 

Internal  Treatment  in  Other  Affections  of  the  Pancreas 629 

Hemorrhage  of  the  Pancreas 631 

Necrosis  of  the  Pancreas       . 631 

Pancreatic  Cysts 632 

Treatment 632 

Tumors  of  the  Pancreas 633 

Treatment 633 

Pancreatic  Calculi 633 

Treatment 633 

Pancreatic  Infantilism 634 

Treatment ■ 634 

CHAPTER  XXXIV. 

Acute  Enterocolitis. 

Acute  Intestinal  Catarrh — Acute  Gastroenteritis — Acute  Colitis — Cholera 

Morbus — Cholera  Nostras — Acute  Diarrhea. 

Etiology 635 

Acute  Infectious  Catarrh 635 


40  contends 

Etiology — 

Alimentary  Catarrh 635 

Catarrh  Due  to  Exposure  to  Cold 635 

Catarrh  from  Intoxication 635 

Pathology 635 

Symptoms 636 

Diagnosis 637 

Prognosis 638 

Treatment 638 

Treatment  of  Cholera  Morbus 642 

CHAPTER  XXXV. 

Chronic  Enterocolitis. 

Chronic  Intestinal  Catarrh — Chronic  Enteritis — Chronic  Colitis — Chronic 

Sigmoiditis. 

Pathology 644 

Symptoms 644 

Diagnosis 645 

Prognosis 647 

Treatment .647 

Of  Cases  with  Diarrhea 647 

Of  Cases  Associated  with  Constipation 650 

Ionization 651 

CHAPTER  XXXVI. 

Enteritis  Membranacea. 

Mucomembranous    Enteritis — Mucous    Colitis — Pseudomembranous    Enteritis — 

Tubular  Diarrhea. 

Pathology 652 

Symptoms 653 

Treatment -  653 

Dietetic 654 

Laxatives 656 

Hydrotherapeutic  Measures 656 

Palliative  Treatment 658 

CHAPTER  XXXVII. 

Chronic  Constipation. 

Atonic  Constipation;  Spastic  Constipation;  Fragmentary  Constipation. 

Atonic  Constipation 659 

Symptoms - 660 

Treatment 661 

Sawdust  and  Bran 662 

Agar K 662 

Liquid  Petrolatum 664 

"Grape  Cures" 664 

Massage 664 

Lavage 666 

Yeast 666 


co.XTi'Xrs  4i 

Uonid  ( !onstipation — 
Treatment — 

Hormonal 667 

Surgical  Treatment •     •  668 

Spastic  Constipation 668 

Diagnosis ()6^ 

Treatment 67° 

Dietetic 67° 

Mechanical        671 

Electrical 671 

Hot  and  Cold  Air  Douche 671 

Enemata 671 

Purgatives 6/2 

Fragmentary  Constipation 672 

Treatment 672 

CHAPTER  XXXVIII. 
Chronic  Diarrhea. 
Gaslrogenic  Diarrhea;  Intestinal  Fermentative  Dyspepsia;  Nervous  Diarrhea. 

Gastrogenic  Diarrhea 6/3 

Symptoms 67o 

Treatment 676 

Intestinal  Fermentative  Dyspepsia •  677 

Diagnosis 6/8 

Treatment 679 

Nervous  Diarrhea 680 

Symptoms 681 

Diagnosis 681 

Treatment 681 

CHAPTER  XXXIX. 

Intestinal  Toxemia,  Intestinal  Stasis,  and  Ileal  Regurgitation. 

Intestinal  Toxemia 683 

Intestinal  Stasis 683 

Ileal  Regurgitation 684 

Etiology : 684 

Course  of  Intestinal  Toxemia 685 

Bacterial  Growth 686 

Indican 686 

Types  of  Intestinal  Putrefaction 687 

Indolic  Type 687 

Saccharobutyric  Type 687 

Combined  Indolic  and  Saccharobutyric  Type 688 

Symptoms 688 

Treatment 689 

Antiseptic  Diet '  •  689 

Whey •      •  690 

Buttermilk 690 

Sour  Milk    . 690 

Carbohydrates 690 


42  CONVENTS 

Treatment — 

Antagonistic  Bacteria 691 

Antiseptic  Medication 692 

Treating  the  Constipation 694 

Duodenal  Lavage 695 

Mechanical  Treatment 696 

Surgical  Treatment 696 

CHAPTER  XL. 

Flatulence,  Meteorism,  and  Tympanites. 

Origin  of  Cases 698 

Exogenous 699 

Endogenous- 699 

Microorganisms - 699 

Food  Decomposition 700 

Treatment 700 

Diet 701 

Massage   .      . : 702 

Medication 702 

CHAPTER  XLI. 

Ulcers  of  the  Intestine. 

Duodenal  Ulcer — Ulcus  Rotundum  Duodeni- — Peptic  Ulcer  of  the  Duodenum; 

Jejunal  Ulcer. 

Duodenal  Ulcer 705 

Etiology 705 

Symptoms 706 

Diagnosis 707 

Palpation  and  Percussion .      .  708 

Determination  of  Gastric  Secretion  . 709 

The  Test  for  Occult  Blood 709 

Roentgen  Ray  .      .      . 710 

Polycythemia    .' 710 

Complications 710 

Prognosis 711 

Treatment 711 

Dietetic  and  Medicinal .711 

Surgical 712 

Jejunal  Ulcer 712 

CHAPTER  XLII. 

Ulcers  of  the  Intestine  (Continued). 

Typhoid  Ulcers 713 

Dietetic  Treatment 713 

High  Caloric  Diet 714 

Caloric  Table 715 

Diet  Table 717 

Preparation  of  Vegetable  Soup 717 

General  Directions  for  Feeding 717 


co.XfENfS  13 

CHAPTER    XLIII. 

(Jlcebs  of  the  Intestine  (Continued). 

Acute  and  Chronic  Dysentery 719 

Etiology 719 

Pathology 720 

Symptoms     .           720 

Complications 721 

Prophylaxis 721 

Prognosis 721 

Treatmenl  of  Acute  Dysentery 722 

Ipecacuanha 722 

Emetin 723 

Benzyl  Benzoate  as  a  Synergist 724 

Emetin-Bismuth  Iodid .  724 

Epinephrin 725 

Amphenamine 725 

Bismuth  Subnitrate 726 

Antidysenteric  Serum .  727 

Vaccine 727 

Treatment  of  Chronic  Dysentery 727 

Medicinal 728 

Surgical 729 

CHAPTER  XLIV. 

Ulcers  of  the  Intestine  (Continued). 

Catarrhal  and  Follicular  Ulcers — Ulcerative  Colitis — Ulcerative  Enteritis — 
Ulcerative  Sigmoiditis;  Stercoral  or  Decubital  Ulcers. 

Catarrhal  and  Follicular  Ulcers 730 

Symptoms 731 

Diagnosis 731 

Treatment 732 

Dietetic 732 

Creosote  and  Cod-liver  Oil 732 

Lavage 733 

Dry  Treatment 733 

Vaccines 735 

Surgical  Treatment 735 

Stercoral  or  Decubital  Ulcers 736 

CHAPTER  XLV. 

Tuberculosis;  Syphilis;  Embolus;   Thrombus. 

Tubercular  Intestinal  Ulcers 737 

Diagnosis 738 

Prognosis 738 

Treatment      , 739 

Medicinal 739 

Symptomatic 739 

Specific 740 


44  CONVENTS 

Tuberculosis  of  the  Cecum 740 

Symptoms 740 

Treatment 741 

Syphilitic  Ulcers  of  the  Intestine 741 

Treatment 741 

Embolic  and  Thrombotic  Ulcers 741 

CHAPTER  XLVI. 

Obstruction  of  the  Intestine. 

Ileus — Intestinal  Occlusion — Miserere — Passio  Iliaco. 

Etiology 742 

External  Ileus 742 

Internal  Ileus 743 

Paralytic  and  Spastic  Ileus 744 

Acute  Flexure  of  the  Sigmoid 745 

Symptoms ' 745 

Treatment .  747 

Surgical  Treatment 747 

Massage 749 

Diet 749 

Lavage     . 750 

Enemata 751 

Medication 753 

CHAPTER  XLVII. 

Strictures  of  the  Intestine. 

Strictures  of  the  Small  Intestine 755 

Symptoms 755 

Strictures  of  the  Large  Intestine     . 757 

Symptoms 757 

Treatment  of  Intestinal  Strictures .  758 

Medication 760 

CHAPTER  XLVIII. 

Tumors  of  the  Intestine. 

Carcinoma;   Sarcoma;   Lymphosarcoma;   Adenoma;   Polypi;   Lipoma;   Myoma. 

Malignant  Neoplasms  of  the  Intestine 761 

Carcinoma 761 

Pathology 762 

Carcinoma  of  the  Small  Intestine 762 

Symptoms 763 

Diagnosis " 763 

Carcinoma  of  the  Colon 764 

Symptoms 764 

Diagnosis 764 

Treatment  of  Carcinoma  of  the  Intestine 765 

Sarcoma  and  Lymphosarcoma  of  the  Intestine 766 

Symptoms 767 

Treatment 767 

Benign  Neoplasms  of  the  Intestine 767 


CONTEXTS  45 

CHAPTER  XLIX. 
Appendicitis. 

Appendicular  Inflammation — Circumscribed  /'<  ri  ton  it  is — Paratyphlitis — 
/ '.  rityphlitis    Scoh  coiditis — Scolecitis. 

Acute  Appendicitis 767 

Symptoms 768 

Diagnosis 769 

McBurncy's  Sign 770 

Meltzer's  Sign 770 

Blumberg's  Sign 770 

Blaisdell's  Sign 770 

Traction  on  the  Spermatic  Cord 770 

Cecum  Mobile 770 

Chrome  Appendicitis • 771 

Symptoms 771 

Appendicitis  Larvata 772 

Diagnosis 772 

Rovsing-Chase  Sign 772 

Rutkevich's  Adduction  Sign 772 

Bastedo's  Dilatation  Sign 773 

Morris's  Sign 773 

Aaron's  Sign 773 

Friedman's  Sign 773 

Treatment  of  Acute  Appendicitis 773 

Early  Operation 773 

The  Ochsner  Method 774 

Purgatives 776 

Diet 777 

Morphin  and  Opium 778 

Treatment  of  Chronic  Appendicitis 779 

Drinking  Cures 779 

Vaccines  and  Phylacogens 780 

CHAPTER  L. 

Nervous  Diseases  of  the  Intestine. 
Enterospasm;  Tormina  Intestinorum  Nervosa;  Paresis;  Enteralgia. 

Enterospasm 781 

Symptoms 781 

Treatment 781 

Tormina  Intestinorum  Nervosa       .            7S2 

Treatment 782 

Paresis  of  the  Intestine 782 

Treatment 783 

Enteralgia  (Enteralgia  Nervosa— Intestinal  Colic— Colica  Flatulenta)  .      .  783 

Treatment 784 


46  CONTENTS 


CHAPTER  LI. 

Perisigmoiditis — Diverticulitis — Peridiverticulitis — Sigmoiditis; 
Idiopathic  Dilatation  of  the  Colon. 

Perisigmoiditis 785 

Diverticulitis 786 

Diverticula  of  the  Sigmoid  Flexure       .      .      .      ...      .      .      .      .      .  787 

Perisigmoiditis  with  Thickening  of  Gut  Wall 789 

Symptoms 789 

Treatment 790 

Chronic  Perisigmoiditis .      .      .'    .  790 

Idiopathic  Dilatation  of  the  Colon — Hirschsprung's  Disease — Congenital 

Megacolon — Congenital  Dilatation  of  the  Colon  ......  790 

Etiology   .....' 791 

Symptoms 792 

Treatment 793 

CHAPTER  Lit' 

The  Animal  Parasites  of  the  Intestine. 

Tapeworms 794 

Taenia  Saginata 794 

Taenia  Solium 794 

Bothriocephalus  Latus 794 

Hymenolepis  Nana 794 

.    Mode  of  Infection .      .      .795 

Treatment 797 

Ascaris  Lumbricoides  (Round  Worm)  .    •  .      ; 800 

Symptoms      .      .      .  -    . 800 

Diagnosis 800 

Treatment 801 

Oxyuris  Vermicularis  (Pin worm —Thread  Worm — Seat  Worm — Maggot 

Worm— Awltail) . 803 

Symptoms      . 803 

Diagnosis 804 

Treatment 805 

Ankylostoma  Duodenale — Uncinaria  Americana  (Uncinariasis — Hook- 
worm Disease— Necator  Americanus— Miners'  Anemia— Strongy- 
lus  Duodenalis — Dochmius   Duodenalis—  Uncinaria  Duodenalis  — 

Ground-itch  Anemia) 806 

Incidence 806 

Origin 808 

Pathology 810 

Symptoms 811 

Diagnosis 811 

Treatment 812 

Trichocephalus  Dispar 814 

Treatment 815 

Anguillula  Intestinalis  (Strongyloides  Stercoralis) 815 

Symptoms .  816 

Treatment 816 


CONTENTS  47 

Trematodes 816 

Treatment 818 

Trichina  Spiralis 818 

Treatmenl 820 

Myiasis  Intestinalis 820 


CIIAITKR    LIII. 

I  )isk  \si;s  of   nii:   Rectum. 

Hemorrhoids;    Tumors  of  the  Rectum;  Strictures  of  the  Rectum;   Proctitis; 

Ulcers  of  the  Rectum;  Prolapse  of  the  Rectum;  Proctospasm; 

Paresis;  Coccygodynia. 

Hemorrhoids 821 

Symptoms 822 

Treatment 822 

Mineral  Waters 823 

Control  of  Hemorrhage 823 

Pyramidal  Ice-bag 824 

Anodynes 824 

Pessaries 826 

Extirpation 827 

Stretching  the  Sphincter 827 

Extra-anal  Method 827 

Injection  Treatment         828 

Anoscope  (Hirschman) 830 

Electrolysis 831 

Surgical  Treatment 831 

Malignant  Growths 832 

Carcinoma     .                  832 

Symptoms 832 

Diagnosis 833 

Treatment 833 

Sarcoma 834 

Treatment 835 

Benign  Growths 835 

Polypi 835 

Treatment 835 

Lipomata  and  Myomata 836 

Treatment 836 

Papillae , 836 

Treatment 837 

Strictures  of  the  .Rectum • 837 

Symptoms 837 

Diagnosis 837 

Treatment 838 

Dilatation 838 

Crede's  Bougie 838 

Rectal  Dilator  (Roberts) '.      .839 

Rectal  Dilator  (Rosenberg) 840 


48  CONTENTS 

Proctitis 841 

Symptoms 841 

Diagnosis 841 

Treatment 842 

Ulcers  of  the  Rectum 843 

Diagnosis 844 

Treatment 844 

Prolapse  of  the  Rectum  (Procidentia  Recti) 845 

Treatment 846 

Rectal  Truss  (Esmarch) 847 

Proctospasm 848 

Treatment 849 

Atzperger's  Refrigerator 849 

Paresis  and  Paralysis  of  the  Rectum 849 

Treatment ' .849 

Coccygodynia 850 

Treatment 850 


CHAPTER  LIV. 

Diseases  of  the  Antjs. 
Pruritus  Ani;  Anal  Fistula;  Fissure  of  the  Anus. 

Pruritus  Ani •  851 

Pathogenesis 851 

Local  and  General  Conditions 852 

Treatment 853 

General ■ 853 

Local 853 

Medicinal 854 

Dilatation 855 

Roentgen  Ray 856 

Bacterial  Vaccines 856 

Surgical  Measures 857 

Anal  Fistula 857 

Diagnosis 858 

Treatment 858 

Fissure  of  the  Anus 858 

Symptoms 859 

Treatment 859 

General 860 

Local 860 

Cauterization 860 

Baths ~  ......  861 

Pessaries 861 

Electricity 861 

Divulsion  of  the  Anal  Sphincters 861 

Surgical  Treatment    .      .      . ' •      •  862 

Comparative  Scales  of  the  Metric  and  Ordinary  Weights  and  Measures  862 

Index 863 


DISEASES  OF  THE  DIGESTIVE  ORGANS. 


CHAPTER   I. 
THE  PHYSIOLOGY  OF  DIGESTION. 

Tin;  physiology  of  digestion  appeals  to  the  physician,  the  physi- 
ologist, and  the  chemist  from  slightly  varying  viewpoints.  To  the 
physiologist  and  the  chemist  the  process  itself  is  the  chief  concern. 
The  clinician  must  go  farther:  he  must  not  only  be  conversant 
with  the  changes  which  take  place  under  normal  conditions,  but 
he  must  be  able  to  make  the  necessary  deductions  when  called 
upon  to  treat  abnormal  digestion.  While  the  physiologist  and  the 
chemist  study  the  stomach  or  the  action  of  the  gastric  secretion, 
the  physician  has  to  consider  this  organ  in  its  relation  to  oral  and 
intestinal  digestion  also. 

Digestion  proper  begins  with  the  mastication  and  insalivation 
of  food.  The  food  becomes  more  or  less  intimately  incorporated 
with  the  saliva  before  being  swallowed,  and,  as  we  shall  see,  the 
process  begun  in  the  mouth  continues  in  the  stomach.  It  is  impor- 
tant, therefore,  that  the  condition  of  the  mouth  should  be  the  best 
possible.  Putrefactive  processes,  if  present,  should  receive  prompt 
attention,  and  the  dentist  should  be  consulted  at  regular  intervals. 

By  the  term  digestion  is  understood  the  process  of  rendering 
food  material  absorbable,  a  process  which  is  accomplished  by  the 
disintegrating  and  dissolving  action  of  secretions  containing 
enzymes,  assisted  to  a  greater  or  less  extent  by  mechanical  action. 
These  ferments  or  enzymes  are  found  in  the  saliva,  gastric  juice, 
bile,  and  pancreatic  and  intestinal  secretions. 

SALIVARY   DIGESTION. 

Action  of  the  Saliva. — In  man  and  in  most  of  the  higher  animals 
the  saliva  has  a  twofold  action — physical  and  chemical.  The 
physical  action  of  saliva  consists  in  the  moistening  of  the  food, 
facilitating  mastication  by  the  teeth;  moreover,  by  virtue  of  the 
mucin  it  contains,  all  the  passages  become  lubricated,  rendering 
more  easy  the  act  of  deglutition  and  the  passage  of  the  bolus  of 
food  into  the  stomach.  In  dogs  the  physical  action  of  saliva  is  the 
only  one.  In  herbivorous  and  in  omnivorous  animals,  including 
4 


50  PHYSIOLOGY  OF  DIGESTION 

man,  the 'saliva  has  a  chemical  action  also,  which  is  very  important 
in  its  relation  to  the  digestion  of  starch.  Saliva  has  a  specific 
gravity  of  1.002.  The  secretion  from  the  parotid  gland  contains  a 
ferment,  ptyalin,  which  possesses  the  property  of  converting  starch 
into  dextrin  or  maltose.  While  the  action  of  the  amylase,  ptyalin, 
begins  with  the  food  in  the  mouth,  the  greater  portion  of  salivary 
digestion  is  performed  during  the  first  period  of  digestion  in  the 
stomach;  for  though  the  partaking  of  food  causes  almost  immediate 
secretion  of  hydrochloric  acid  by  the  gastric  glands,  some  time  must 
elapse  (from  twenty  to  forty  minutes)  before  the  acid  secretion  of 
the  stomach  can  penetrate  the  food  sufficiently  to  inhibit  salivary 
digestion.  The  food  material  at  the  fundus  of  the  stomach  may 
remain  undisturbed  for  a  considerable  time  and  thus  escape  mix- 
ture with  the  acid  gastric  juice.  Complete  mastication  of  food, 
in  order  that  the  saliva  may  become  thoroughly  incorporated  with 
it,  is  imperative  for  complete  amylolysis. 

Ptyalin. — Ptyalin,  or  the  diastatic  ferment  of  the  saliva,  converts 
starches  as  well  as  glycogen  into  sugar.  This  ferment  acts  in  a 
slightly  alkaline  or  neutral  medium.  Starches  are  first  converted 
into  maltose  or  isomaltose,  from  which  dextrose  appears  to  be  a 
result  of  inversion  by  maltase.  The  change  takes  place  to  better 
advantage  in  cooked  than  in  raw  starch.  The  several  intermediate 
stages  in  the  transformation  of  starches  are  as  follows :  The  starch 
becomes  liquefied  so  that  it  forms  a  true  solution  rather  than  a 
suspension.  The  product  of  the  initial  stage  of  salivary  digestion  is 
known  as  amylodextrin,  and  turns  blue  when  treated  with  a  dilute 
Lugol  solution.  As  the  process  continues,  the  color  produced  by 
the  Lugol  solution  gradually  changes  from  a  blue  to  a  violet  red 
and  finally  to  a  mahogany  brown.  Starches  modified  to  this  extent 
are  known  as  erythrodextrin.  As  the  process  of  salivary  digestion 
continues  still  further,  no  color  change  is  obtained  from  the  addi- 
tion of  the  Lugol  solution;  the  term  achroodextrin  is  used  to  desig- 
nate the  product  of  this  stage  of  the  digestive  process.  These 
changes  may  be  summarized  as  follows : 

1.  Amylodextrin  (amidulin,  soluble         Stains   blue   with  iodin  or   Lugol 

starches).  solution. 

2.  Erythrodextrin.  Lugol  solution  changes  first  to  a 

violet  blue,  then  red  violet,  and 
finally  mahogany  brown. 

3.  Achroodextrin.  No  color  change  produced  by  Lugol 


4.  Maltose. 

5.  Dextrose. 


solution. 


MOVEMENTS  OF  THE  STOMACH. 


Solid  food  remains  in  the  stomach  for  several  hours,  where  it  is 
subjected  to  the  action  of  a  special  fluid,  the  gastric  juice.  During 
this  time,  by  muscular  contractions  of  the  walls  of  the  stomach, 
the  thinner  portions  of  the  chymified  material  are  ejected  through 


MOVEMENTS  OF  THE  STOMACH  51 

the  pylorus  into  the  intestine.  The  tonic  closure  of  the  sphincters 
at  the  cardia  and  pylorus  shuts  off  the  food  from  the  remainder  of 
the  alimentary  canal  except  at  such  times  as  there  is  a  relaxation 
of  the  pylorus  to  permit  the  passage  of  chyme  into  the  duodenum. 
During  the  initial  stages  of  gastric  digestion  the  pylorus  is  closed 
so  firmly  that  upon  excision  of  the  stomach  none  of  its  contents 
will  escape.  As  digestion  advances,  however,  the  pylorus  offers 
less  and  less  resistance,  until  finally  it  yields  to  permit  the  passage 
into  the  duodenum  of  digested  gastric  contents. 

Since  the  discovery  of  the  Roentgen  ray,  interesting  studies 
have  been  made  of  the  movements  of  the  stomach.  Cannon, 
among  others,  has  devoted  much  attention  to  the  subject.  By 
giving  an  animal  food  mixed  with  bismuth  subnitrate,  he  was 
able  to  obtain  roentgenograms  of  the  stomach,  the  bismuth  being 
opaque  to  the  Roentgen  ray.  From  these  studies  it  has  been  con- 
firmed that  peristaltic  movements  take  place  soon  after  the  entrance 
of  food  into  the  stomach.  The  stomach  "consists  of  two  parts 
physiologically  distinct" — the  cardiac  portion,  a  food  reservoir  in 
which  salivary  digestion  continues,  and  the  pyloric  portion,  the 
seat  of  active  gastric  digestion.  The  food  passes  from  the  former 
to  the  latter  by  tonic  contraction  of  the  muscles. 

The  peristaltic  muscular  activity  is  confined  to  the  pyloric 
portion.  The  efficiency  of  peristalsis  in  mixing  the  food  depends 
upon  the  contraction  of  the  pyloric  sphincter,  so  that  each  peri- 
staltic ring  or  contraction  wave  forces  the  gastric  contents  into  a 
blind  pouch.  Unable  to  pass  out  through  the  pyloric  exit,  the  food 
is  forced  back  through  a  succeeding  peristaltic  ring,  and  in  this 
way  is  brought  thoroughly  under  the  influence  of  the  glandular 
secretions  of  the  pyloric  portion  of  the  stomach.  In  the  human 
stomach  during  digestion  the  peristaltic  waves  occur  at  intervals 
of  about  twenty  seconds.  In  periods  of  relaxation  of  the  pyloric 
sphincter,  as  digestion  progresses,  these  contraction  waves  force 
some  of  the  fluid  contents  of  the  stomach  into  the  duodenum. 
After  the  propulsion  of  a  certain  quantity  of  fluid  chyme  into  the 
intestine  the  pylorus  remains  closed  until  the  acid  on  the  distal 
side  of  the  pyloric  sphincter  becomes  neutralized  by  the  bile  and  the 
alkaline  pancreatic  secretion  in  the  duodenum.  The  acid  chyme 
provides  a  chemical  stimulus  for  pancreatic  secretion.  The  open- 
ing and  closing  of  the  pylorus  is  also  dependent  upon  food  being 
swallowed  with  an  appetite.  We  now  know  there  is  a  psychic 
motility  of  the  stomach  similar  to  its  psychic  secretion. 

By  mixing  bismuth  subnitrate  with  the  food  and  obtaining  a 
roentgenogram  of  the  stomach  during  the  process  of  digestion, 
it  has  been  learned  further  that  carbohydrate  foods  begin  to  pass 
out  of  the  stomach  in  a  comparatively  short  time  after  ingestion, 
requiring  only  about  one-half  as  much  time  for  gastric  digestion  as 
proteins.     When  taken  alone,  fats  have  been  found  to  remain  for 


52  PHYSIOLOGY  OF  DIGESTION 

a  long  time  in  the  stomach,  and  when  taken  along  with  other  foods 
they  delay  to  a  marked  extent  the  passage  of  the  whole  chymified 
food  mass  into  the  intestine.  If  carbohydrates  be  fed  before  pro- 
teins in  an  experimental  diet,  the  former,  being  nearest  the  pyloric 
portion  of  the  stomach,  will  be  almost  immediately  propelled  into 
the  intestinal  canal,  leaving  the  protein  behind  to  be  acted  upon 
by  the  gastric  juice.  To  reverse  the  order  of  feeding  will  retard 
the  passage  of  carbohydrates  into  the  duodenum. 

Liquids  pass  through  the  empty  stomach  by  a  well  defined  route 
along  the  small  curvature  called  the  "water  way"  of  the  stomach. 
Even  when  the  stomach  is  full,  some  of  the  liquids  follow  this  path 
and  directly  enter  the  duodenum. 

The  stomach  is  essentially  an  automatic  organ.  The  excised 
stomach  when  kept  at  the  temperature  of  the  body  continues  to 
execute  regular  movements.  It  has  nerve  plexuses  within  its 
walls  and  is  also  connected  with  the  cerebrospinal  and  sympathetic 
systems.  During  digestion  the  normal  peristaltic  movements  of 
the  stomach  are  in  all  probability  due  to  a  local  reflex  from  Auer- 
bach's  plexus.  Stimulation  of  the  sympathetic  fibers  has  an  inhibi- 
tory effect  upon  gastric  peristalsis.  It  has  been  found  that  the 
impulses  received  along  the  path  of  the  vagus  are  motor.  The 
automatic  rhythmical  contraction  is  inherent  in  the  muscular  coat 
of  the  stomach,  however,  and  is  merely  regulated  by  impulses  from 
the  central  nervous  system  passing  down  the  vagi,  and  from  the 
sympathetic  system  by  way  of  the  splanchnic  nerves.  The  pyloric 
sphincter  as  well  as  the  remainder  of  the  musculature  of  the  stomach 
is  supplied  by  motor  fibers  from  the  vagus;  on  the  other  hand, 
stimulation  of  the  splanchnic  nerves  causes  the  contracted  stomach 
to  dilate  and  the  pylorus  to  relax. 

GASTRIC  DIGESTION. 

We  are  indebted  to  Pawlow,  the  Russian  investigator,  for  new 
knowledge  concerning  the  physiology  of  digestion,  especially  that 
portion  of  the  subject  which  is  most  directly  concerned  with  gastric 
and  duodenal  secretion.  Pawlow's  experiments  enabled  him  to 
study  the  gastric  secretion  in  dogs  after  feeding  certain  foods,  and 
the  effect  of  the  so-called  sham  feeding  upon  gastric  secretion. 
This  investigator  has  also  studied  the  relation  between  the  action 
of  gastric  and  that  of  pancreatic  juice.  These  studies  were  facili- 
tated by  the  establishment  of  a  gastric  fistula  leading  from  a  blind 
pouch  or  cul-de-sac.  We  have  learned  that  the  glands  of  the 
stomach  continue  to  secrete  gastric  juice  until  the  food  enters  the 
duodenum,  the  quantity  of  secretion  being  in  proportion  to  the 
quality  of  food  ingested.  While  the  secretion  of  the  stomach 
under  normal  conditions  is  always  acid,  the  acidity  increases  as  the 
gastric  juice  is  more  rapidly  secreted.    Furthermore,  the  digestive 


GASTRIC  DIGESTION  53 

power  of  the  gastric  juice  is  subject  to  variation,  depending  upon 
the  kind  of  food  ingested.  Gastric  juice  secreted  after  a  bread 
diet  is  said  to  possess  the  greatest  digestive  power,  while  that  of 
least  strength  follows  the  partaking  of  a  purely  milk  diet.  The 
total  acidity,  on  the  other  hand,  is  greatest  after  meat  and  lowest 
after  bread  diet.  From  the  point  of  view  of  weight,  meat  requires 
the  greatest  and  milk  the  smallest  amount  of  gastric  juice.  In  the 
majority  of  cases  the  so-called  psychic  secretion,  or  that  produced 
by  the  sight,  taste,  or  odor  of  food,  constitutes  the  commencement 
of  gastric  secretion.  Such  substances  as  meat  broths  and  meat 
juices  or  solutions  of  meat  extracts  are  excellent  stimulants  to 
gastric  secretion.  After  gastric  secretion  has  begun,  further  diges- 
tive power  is  developed  by  the  ingestion  of  bread  and  egg  foods. 
The  amalgamation  of  protein  and  starch  in  bread  accounts  for  the 
high  digestive  power  that  "bread  juice"  is  said  to  contain.  Fats 
have  the  effect  of  diminishing  or  inhibiting  secretion;  they  do  not 
in  any  way  stimulate  it. 

Enzymes. — The  study  of  enzymes  has  engrossed  the  attention 
of  a  number  of  observers  during  recent  years.  The  commonly 
accepted  view  of  the  mode  of  action  of  these  ferments  is  that  origi- 
nally propounded  by  Ostwald,  namely,  that  they  act  by  catalysis. 
The  term  is  employed  by  chemists  to  designate  a  kind  of  reaction 
which  is  brought  about  by  the  mere  contact  or  presence  of  certain 
substances  known  as  catalyzers,  which  themselves  appear  to  remain 
unchanged.  As  defined  by  Starling,  a  catalyzer  is  a  substance 
which  will  increase  the  velocity  of  a  reaction  without  adding  in 
any  way  to  the  energy  changes  involved  in  the  reaction  or  taking 
part  in  the  formation  of  end  products.  The  activity  of  enzymes 
appears  to  be  specific  in  character;  e.  g.,  those  ferments  which  act 
upon  carbohydrates  are  not  capable  of  producing  any  effect  upon 
fats  or  proteins. 

The  enzymes  of  the  body  are  colloidal  in  structure,  with  an 
unknown  composition.  Most  of  them  are  soluble  in  water,  glycerin, 
or  physiologic  salt  solution.  They  are  destroyed  completely  by 
high  temperatures  (140°  to  175°  F.),  and  their  physiologic  action  is 
retarded  in  whole  or  in  part  by  temperatures  only  slightly  below 
the  normal.  The  enzymes  are  capable  of  their  greatest  activity  at 
the  temperature  of  the  human  body.  They  may  be  precipitated 
from  solution,  in  part  at  least,  by  alcohol,  which  property  is  utilized 
in  obtaining  purified  specimens.  Enzymes  may  exist  in  an  inactive 
or  latent  form  in  the  cells  which  produce  them,  and  may  be  still 
inactive  after  they  are  secreted.  The  inactive  or  latent  forms  of 
enzymes  are  known  as  zymogens  or  proenzymes.  Before  the 
zymogen  can  become  effectual,  it  requires  the  aid  of  some  other 
agent.  The  inorganic  substances  which  render  enzymes  active  agents 
in  digestion  are  known  as  activators;  organic  substances  which 
produce  the  same  result  are  called  kinases. 


54  PHYSIOLOGY  OF  DIGESTION 

The  fundus  and  the  pyloric  portion  of  the  stomach  are  supplied 
with  tubular  glands  which  exhibit  marked  differences  in  structure 
in  the  two  parts.  In  man  the  tubular  glands  of  the  fundus  are 
provided  with  a  duct  lined  with  simple  columnar  epithelial  cells, 
into  which  duct  empty  one  or  two  secreting  tubules  supplied  with 
two  varieties  of  epithelial  cells,  namely,  central  or  peptic  cells, 
and  parietal  or  oxyntic  cells.  In  the  pyloric  portion  of  the  stomach 
there  is  only  the  one  kind  of  cell,  namely,  the  peptic.  The  parietal 
or  oxyntic  cells  secrete  acid,  while  the  central  or  peptic  cells  provide 
the  pepsinogen  or  pepsin  and  rennin  for  gastric  digestion. 

Pepsin.— Pepsin,  or  rather  pepsinogen,  is  active  only  in  the 
presence  of  free  hydrochloric  acid.  Hydrochloric  acid  possesses 
the  property  of  converting  pepsinogen  into  pepsin  more  thoroughly 
than  can  be  done  by  any  other  mineral  acid.  Pepsinogen,  or  pep- 
sin in  the  latent  state,  has  such  a  high  resistant  power  that  it  is 
present  even  in  markedly  advanced  stages  of  catarrhal  gastritis, 
as  well  as  in  carcinoma.  Peptids  and  albumoses  constitute  the 
end-result  of  peptic  digestion.  The  conversion  of  proteins  and 
gelatinous  substances  into  soluble  albumoses  takes  place  by  degrees, 
so  gradually  in  fact  that  it  is  difficult  to  determine  the  intermediate 
products  of  the  process. 

Hydrochloric  Acid. — Hydrochloric  acid  acts  in  various  ways  in 
performing  and  facilitating  the  normal  process  of  digestion.  In 
the  first  place,  it  is  antizymotic  and  antiseptic,  destroying  patho- 
genic microorganisms  and  arresting  fermentation  and  putrefaction; 
the  antiseptic  action  of  hydrochloric  acid  continues  in  the  duode- 
num. It  also  acts  as  a  means  of  regulating  peristalsis.  Hydro- 
chloric acid  with  pepsin  converts  food  proteins  into  albumoses; 
pepsin,  however,  is  the  chief  agent  in  this  transformation  process, 
hydrochloric  acid  acting  as  an  adjuvant.  By  hydrochloric  acid 
cane-sugar  is  converted  into  dextrose  and  levulose. 

Normal  Gastric  Juice. — Normal  gastric  juice  is  a  thin,  colorless 
or  nearly  colorless  fluid,  with  a  strongly  acid  reaction  and  a  char- 
acteristic odor;  its  specific  gravity  is  about  1.002.  The  acidity 
of  the  gastric  juice  is  due  to  the  presence  of  free  hydrochloric  acid, 
the  amount  of  which  varies  according  to  the  duration  of  digestion. 
The  acidity  at  the  beginning  of  digestion  is  low,  owing  to  the  fact 
that  a  portion  of  the  acid  is  neutralized  by  the  alkalinity  of  the 
saliva  incorporated  with  the  food.  While  the  gastric  juice  has  a 
more  or  less  constant  acidity,  its  reaction  may  be  diminished  by 
alkalis  in  the  stomach,  or  by  combination  v/ith  the  protein  of  the 
food,  forming  acid-albumins  or  syntonins.  The  normal  acidity  of 
the  gastric  juice  of  man,  estimated  to  be  0.2  per  cent.,  may,  according 
to  Hornberg,  reach  0.4  or  0.5  per  cent,  during  digestion. 

Pawlow,  in  his  work  on  the  digestive  glands,  has  demonstrated 
that  gastric  secretion  is  under  the  control  of  the  nervous  system, 
and  that  the  secretory  fibers  are  contained  in  the  vagus.    If  the 


GASTRIC  DIGESTION  55 

vagus  be  cut  below  the  origin  of  the  recurrent  laryngeal,  so  as  to 
avoid  paralysis  of  the  larynx,  and  sham  feeding  performed,  there 
is  no  gastric  secretion — proving  conclusively  that  the  vagus  contains 
the  secretory  fibers.  The  hypothesis  is  confirmed  by  stimulation 
of  the  peripheral  end  of  the  cut  nerve.  Pawlow's  experiment, 
which  consists  in  dividing  the  esophagus  of  a  dog  in  the  neck,  and 
connecting  the  esophageal  mucous  membrane  with  the  skin  to 
form  a  fistulous  opening,  is  well  known.  Food  fed  to  Pawlow's 
dogs  escaped  through  the  fistulous  opening  in  the  esophagus  with- 
out reaching  the  stomach.  The  sham  meal,  as  the  experimenter 
designates  it,  had  the  effect  of  producing  a  copious  flow  of  gastric 
juice,  so  long  as  the  vagus  was  intact.  The  flow  of  gastric  juice 
resulted  evidently  from  a  stimulation  of  the  secretory  fibers  of  the 
vagus,  by  the  sensations  of  sight,  odor,  taste,  etc.,  during  the  masti- 
cating and  swallowing  of  food.  The  beginning  of  gastric  secretion 
is  psychic. 

Under  normal  conditions  gastric  juice  continues  to  be  secreted 
as  long  as  food  remains  in  the  stomach.  Mechanical  stimulation 
of  the  gastric  mucous  membrane  has  no  effect  upon  the  secretion 
of  the  glands  of  the  stomach.  The  sensation  of  eating  serves  to 
start  the  secretion  in  an  ordinary  meal.  The  afferent  stimuli 
originate  in  the  mouth  and  nostrils  and,  as  stated,  probably  with 
the  sense  of  sight.  The  efferent  path  is  through  the  vagus.  Some 
food  articles,  among  which  are  meat  extracts,  meat  juices,  and 
soups,  and  hi  a  less  degree  milk  and  water,  are  said  to  contain 
substances  which,  when  taken  into  the  stomach,  promote  gastric 
secretion. 

Secretin. — Decoctions  of  the  mucous  membrane  of  the  pylorus 
injected  into  the  blood  are  found  to  increase  the  secretion  of  gastric 
juice.  According  to  Edkins,  secretagogues  preformed  in  the  food 
or  produced  during  digestion  act  upon  the  mucous  membrane  of 
the  pylorus,  giving  rise  to  a  "gastrin,"  or  gastric  "secretin,"  which, 
after  absorption  into  the  blood,  is  carried  to  the  gastric  glands 
and  stimulates  them  to  secretion.  These  chemical  messengers 
determining  the  various  secretions,  such  as  gastric,  pancreatic, 
hepatic,  and  intestinal,  have  been  designated  hormones  (from  opuaw, 
I  arouse  or  excite)  (Starling). 

Pepsin. — The  principal  action  of  pepsin  consists  in  the  conversion 
of  the  proteins  of  the  food  into  peptones.  Soluble  protein,  after 
passing  through  several  intermediate  stages,  the  results  of  which 
have  been  isolated  and  named  acid-albumin,  parapeptone,  and 
propeptone,  becomes  peptone.  The  first  step  in  the  digestion  of 
protein  consists  in  its  conversion  into  an  acid-albumin  (syntonin). 
Under  the  action  of  pepsin,  syntonin  or  acid-albumin  undergoes 
hydrolysis,  producing  protalbumoses.  Under  the  continued  influ- 
ence of  pepsin  these  bodies  undergo  further  hydrolysis,  with  the 
consequent  formation  of  secondary  proteoses  (deutero-albumoses) . 


56  PHYSIOLOGY  OF  DIGESTION 

The  further  hydrolysis  of  the  secondary  proteoses  results  in  the 
production  of  peptones. 

Rennin. — Rennin  is  analogous  to  pepsin  in  that  it  is  formed  in 
the  peptic  or  central  cells  and  is  present  in  the  cells  as  a  zymogen. 
The  conversion  of  prorennin  into  the  active  enzyme  takes  place 
very  readily  under  the  influence  of  hydrochloric  acid.  Rennin 
curdles  the  casein  of  milk,  and  this  apparently  is  its  only  action  in 
the  stomach.  Casein,  the  chief  protein  in  milk,  has  an  important 
nutritive  value.  It  is  digested,  like  other  proteins,  by  pepsin  in  the 
stomach  and  trypsin  in  the  intestine,  the  end-result  of  the  process 
of  gastric  digestion  being  peptone. 

Lipase. — It  has  been  demoastrated  that  the  normal  gastric 
mucosa  in  man  secretes  a  lipase,  or  fat-splitting  ferment,  which 
acts  readily  upon  the  emulsified  fats  of  milk,  cream,  or  yolk  of 
egg.  This  ferment,  which  is  secreted  by  the  cells  of  the  fundus 
of  the  stomach,  has  been  extracted  by  means  of  glycerin.  It  is 
inactive  in  an  alkaline  medium. 

Fats  in  gastric  digestion  become  liquefied  by  the  heat  of  the  body 
and,  being  thus  set  free  from  their  intimate  admixture  with  other 
foodstuffs,  are  distributed  throughout  the  chyme  by  the  movements 
of  the  stomach.  In  this  way  they  are  prepared  for  digestion  by  the 
pancreatic  juice  and  bile  in  the  intestine. 

#  Absorptive  Power  of  the  Stomach. — It  is  probable  that  the  absorp- 
tive power  of  the  stomach  is  limited  to  such  substances  as  salts, 
sugars,  and  dextrins  that  may  have  been  formed  from  starch  in 
salivary  digestion.  Absorption  does  not  take  place  readily  in  the 
stomach;  it  is  a  distinctive  feature  of  intestinal  digestion.  Water 
when  taken  alone  is  practically  not  at  all  absorbed  from  the  stomach, 
but  as  soon  as  introduced  begins  to  pass  into  the  intestine  in  a  series 
of  spurts,  by  the  contraction  of  the  walls  of  the  stomach. 

INTESTINAL  DIGESTION. 

Digestion  by  the  Small  Intestine. — While  the  food  remains  in 
the  stomach  it  undergoes  a  merely  preparatory  treatment  that 
renders  it  suitable  for  intestinal  digestion.  The  principal  work 
in  the  digestive  process  is  performed  by  the  small  intestine  with 
the  cooperation  of  the  glands  connected  with  it — the  liver  and  the 
pancreas. 

According  to  Pawlow's  investigations  it  must  be  assumed  that 
the  intestinal  mucosa  is  provided  with  organs  of  perception  which 
are  affected  by  the  chemical  quality  of  the  intestinal  contents, 
and  which  regulate  by  way  of  reflexes  the  work  of  the  digestive 
glands  and  the  mechanical  function  of  the  intestine.  These  reflexes 
are  partly  chemical,  inducing  the  biliary  flow  and  the  secretion 
of  pancreatic  juice.  In  this  process  the  quantity  and  composition 
of  these  juices  adapt  themselves  closely  to  the  composition  of  the 


INTESTINAL  DIGESTION  57 

ingested  food.  Obviously,  therefore,  the  digestive  glands  arc  highly 
accommodative,  as  they  must  needs  he  in  order  to  perforin  their 
allotted  task. 

Aside  from  the  chemical  reflexes,  there  are  also  motor  reflexes 
at  work,  one  of  which  belongs  to  the  duodenal  mucosa.  The 
gastric  hydrochloric  acid  acting  on  the  intestinal  mucosa  regulates 
the  opening  and  closing  of  the  pylorus.  As  soon  as  the  bile,  pan- 
creatic juice  and  succus  entericus  in  the  duodenum  are  acidified  by 
the  acid  chyme,  and  hydrochloric  acid  is  in  contact  with  the  duo- 
denal mucosa,  the  pylorus  closes  itself.  This  acid  also  contracts 
a  part  of  the  duodenum  adjacent  to  the  pylorus. 

Pancreatic  Juice. — The  pancreas  is  the  most  important  of  the 
digestive  glands.  In  the  hungry  state  and  during  the  period  of 
digestive  rest  it  is  pale,  relaxed,  and  inactive,  but  the  moment 
food  is  introduced  into  the  stomach  it  at  once  takes  up  its  work, 
and,  owing  to  increased  blood  supply,  becomes  distended  and 
assumes  a  rose-red  color.  It  begins  to  secrete  juice  as  soon  as 
the  acid  gastric  contents  enter  the  small  intestine.  The  prin- 
cipal inciting  factor  of  pancreatic  secretion  is  the  hydrochloric 
acid  of  the  stomach  as  it  enters  the  duodenum.  The  duodenal 
mucosa  contains  prosecretin,  which  is  transformed  into  secretin 
by  the  hydrochloric  acid.  Secretin  is  absorbed  and  stimulates 
the  flow  of  pancreatic  juice.  The  pancreatic  secretion  is  propor- 
tionate in  quantity  and  alkalescence  to  the  quantity  and  acidity 
of  the  gastric  juice.  The  quantity  of  organic  constituents  it  con- 
tains (ferments)  is  very  small,  while  the  quantity  of  inorganic 
constituents  (alkalis)  is  exceedingly  large.  However,  the  juice  of 
the  pancreas  is  never  quite  devoid  of  ferments.  The  combination 
of  the  gastric  juice  with  the  pancreatic  juice  explains  why  the  most 
important  digestive  processes  can  take  place  without  any  note- 
worthy change  in  the  alkalinity  of  the  blood.  The  acid  component 
of  the  sodium  chlorid  contained  in  the  blood  (chlorin)  enters  the 
peptic  glands  and  then  the  stomach,  while  the  basic  element  (sodium) 
serves  the  pancreas  as  sodium  carbonate  in  the  preparation  of  its 
secretion.  The  two  components  of  sodiirm  chlorid  become  reunited 
as  the  acidity  of  the  chyme  is  neutralized  by  the  alkalinity  of  the 
pancreatic  secretion. 

Water,  fats  and  psychic  influences  also  stimulate  the  pancreatic 
secretion,  while  solutions  of  potassium  or  sodium  bicarbonate  have 
an  inhibiting  effect  upon  the  formation  of  pancreatic  juice. 

The  pancreatic  solution  is  a  limpid,  colorless  fluid,  containing 
0.2  to  0.4  per  cent,  of  sodium  carbonate  and  three  ferments.  The 
quantity  secreted  in  twenty-four  hours  depends  upon  the  quantity 
and  composition  of  the  ingested  food. 

The  three  ferments  of  the  pancreatic  secretion  are : 

1.  Trypsin. — Trypsin  in  its  pure  state  is  found  in  the  pancreatic 
juice  after  a  pure  meat  diet;  otherwise  there  will  be  found  tryp- 


58  PHYSIOLOGY  OF  DIGESTION 

sinogen,  which  is  a  proenzyme  that  is  later  activated  into  trypsin 
by  the  enterokinase  of  the  intestinal  juice.  Enterokinase  is  only 
secreted  when  trypsinogen  enters  the  intestine — so  trypsinogen 
produces  its  own  kinase  by  a  specific  chemoreflex.  Peptic  diges- 
tion comes  to  an  end  in  the  stomach  when  the  proteins  have  been 
changed  into  albumoses,  but  trypsin  continues  the  process  by 
digesting  the  albumoses,  thereby  forming  the  foundation  of  the 
albuminous  molecules  or  aminoacids. 

2.  Amylopsin. — Amylopsin  seems  to  be  present  in  the  pancreatic 
juice  as  a  complete  ferment  which  changes  starch  into  dextrin  and 
maltose. 

3.  Steapsin. — Steapsin  is  the  fat-splitting  ferment  of  the  pan- 
creas, splitting  neutral  fats  into  glycerin  and  fatty  acids,  principally 
palmitic,  stearic,  and  oleic.  Like  trypsinogen,  the  fat-splitting 
ferment  must  first  be  activated,  and  this  is  done  by  the  bile. 

The  Bile. — The  quantity  of  bile  secreted  in  the  liver  of  an  adult 
in  one  day  amounts  to  from  400  to  800  Cc. — a  pint  to  a  pint 
and  a  half.  Bile  differs  from  the  other  digestive  juices  in  the  fact 
that  it  is  continuously  produced,  even  in  hunger,  and  its  composi- 
tion is  only  slightly  affected  by  the  nature  of  the  food.  The 
bile  thus  continuously  secreted  is  stored  up  in  the  gall  bladder 
and  is  of  a  mucoviscous  consistence  owing  to  its  becoming  mixed 
on  its  way  through  the  bile  ducts  and  in  the  gall  bladder  with  the 
muco-albuminous  secretion  of  the  gall-bladder  mucosa.  While  in 
the  gall  bladder  the  bile  becomes  considerably  inspissated  from  the 
loss  of  water  and  grows  darker  in  color  and  more  viscid. 

The  characteristic  constituents  of  bile  are  the  biliary  acids  and 
pigments.  Other  constituents  are  fats,  soaps,  lipoids  (cholesterol, 
lecithin),  nucleoprotein,  urea,  and  mineral  salts  (salts  of  sodium, 
phosphorus,  calcium,  and  magnesium). 

The  biliary  acids,  glycocholic  and  taurocholic,  are  found  in  the 
bile  as  sodium  salts.  Sodium  glycocholate  takes  up  water  in  the 
intestine  under  the  influence  of  dilute  acids  and  alkalis,  and  through 
the  action  of  ferments  is  decomposed  into  glycochol  (amino-acetic 
acid)  and  cholalic  acid.  Sodium  taurocholate  is  simply  decomposed 
into  taurin  (amino-ethyl-sulphonic  acid)  and  cholalic  acid. 

The  biliary  pigments  are  bilirubin  and  biliverdin;  they  are  non- 
ferric  derivatives  of  the  blood  pigment.  Biliverdin  is  produced  by 
oxidation  of  bilirubin.  These  pigments  act  like  acids,  forming 
soluble  combinations  with  alkalis.  In  the  intestine  bilirubin  is 
reduced  to  hydrobilirubin,  the  normal  fecal  pigment,  through  the 
action  of  intestinal  bacteria. 

The  flow  of  bile  into  the  intestine  is  controlled  by  a  reflex  mechan- 
ism dependent  upon  two  constituents  of  the  intestinal  contents: 
peptone  and  fat.  The  entrance  of  peptone  and  fat  into  the  duo- 
denum causes  the  normal  flow  of  bile  into  the  intestine. 

Bile  does  not  seem  to  have  any  independent  digestive  power 


INTESTINAL  DIGESTION  59 

of  its  own.  It  acts  as  an  auxiliary  to  the  activity  of  the  pancreatic 
juice  by  activating,  as  stated  above,  the  steapsin.  Like  the  intes- 
tinal and  pancreatic  secretions,  it  emulsifies  fats,  owing  to  their 
containing  easily  decomposable  alkalis.  Its  alkaline  character  also 
assists  in  neutralizing  the  acidity  of  the  chyme  coming  from  the 
stomach.  Otherwise,  bile  can  only  be  regarded  as  a  secretion 
which  carries  into  the  intestine  many  metabolic  end-products — 
for  instance  cholesterol,  which  is  kept  in  solution  in  the  presence 
of  biliary  acid  salts.  Cholesterol  is  probably  a  decomposition 
product  which  is  regularly  formed  in  the  metabolic  processes  of 
the  living  protoplasm;  it  is  demonstrable  in  many  cells.  The 
biliary  acid  salts  are  absorbed  from  the  intestine  and  carried  back 
to  the  liver. 

The  Intestinal  Juice. — The  consistence  of  intestinal  juice  differs 
according  to  location.  In  the  upper  segments  of  the  intestine  it 
is  more  liquid  and  watery,  in  the  lower  more  viscous  and  mucous. 
These  variations  correspond  to  the  different  functions  of  the  parts. 
In  the  small  intestine  the  strongly  acid  chyme  emerging  from  the 
stomach  requires  an  abundant  quantity  of  liquid  alkaline  juice  to 
neutralize  its  acidity  and  to  render  the  food  constituents  alkaline. 
In  the  large  intestine,  especially  hi  its  lower  parts,  a  mucous  con- 
sistence of  the  intestinal  juice  facilitates  the  passage  of  the  feces 
and  protects  the  intestinal  mucosa  from  mechanical  and  chemical 
injury. 

The  juice  of  the  small  intestine  is  derived  principally  from  the 
glands  of  Lieberkuhn.  Unlike  other  digestive  juices,  it  is  secreted 
through  the  agency  of  a  local  mechanical  irritation.  It  contains 
0.4  to  0.5  per  cent,  of  calcium  carbonate,  0.5  to  0.6  per  cent,  of 
sodium  chlorid,  and  5  per  cent,  of  a  mucoid  albuminous  substance 
which  is  regarded  as  a  mucin  or  nucleoprotein. 

Its  high  percentage  of  calcium  carbonate  indicates  that  its 
principal  task  is  the  neutralization  of  acids  and  the  emulsification 
of  fats.  The  acidity  of  the  chyme  is  effectively  neutralized  by 
its  action,  and  with  this  process  an  important  mechanical  effect 
is  associated.  Just  as,  in  the  test  tube,  the  intestinal  juice  becomes 
strongly  effervescent  upon  addition  of  hydrochloric  acid,  so  will 
food  particles  saturated  with  hydrochloric  acid  effervesce  when 
coming  in  contact  with  the  alkaline  intestinal  juice  of  the  small 
intestine.  As  a  consequence  carbon  dioxid  is  rapidly  and  freely 
developed,  causing  the  smallest  food  particles  to  be  disintegrated. 
This  results  in  a  loosening  of  the  whole  mass  of  chyme,  so  that  the 
digestive  ferments  have  free  access  to  all  its  parts. 

The  juice  of  the  small  intestine  contains  a  number  of  important 
ferments  secreted  by  the  epithelia  of  the  tract.  They  are:  maltase, 
lactase,  invertin,  erepsin,  enterokinase,  and  probably  also  a  cytase. 

Maltase  changes  maltose  into  dextrose;  lactase  splits  sugar  of 
milk  into  dextrose  and  galactose;  invertin  splits  cane-sugar  into 


60  PHYSIOLOGY  OF  DIGESTION 

dextrose  and  levulose.  Erepsin  does  not  attack  intact  protein, 
but  decomposes  its  digestive  products  (albumoses  and  peptone) 
into  aminoacids;  casein  is  likewise  split  by  erepsin.  As  already 
mentioned,  enterokinase  converts  trypsinogen  of  the  pancreatic 
juice  into  trypsin;  it  is  not  always  present  in  the  intestinal  juice, 
for  on  mechanical  irritation  of  the  intestinal  mucosa  a.  juice  is 
secreted  which  is  free  from  enterokinase.  Possibly  enterokinase 
is  related  to  the  lymphatic  apparatus  of  the  intestinal  mucosa. 
Investigations  made  by  Lohrisch  on  cellulose  digestion  have  made 
it  appear  probable  that  in  human  intestinal  juice  there  is  also  a 
cellulose-dissolving  ferment,  or  a  cytase. 

Absorption  in  the  Small  Intestine. — Absorption  generally  takes 
place  through  the  numerous  intestinal  villi  which  are  immersed 
in  the  chyle.  These  villi  absorb  water,  salts,  and  all  such  sub- 
stances as  have  become  liquefied  through  the  processes  of  digestion 
and  are  required  by  the  organism  to  sustain  its  equilibrium  and 
growth.  The  villi  are  thick  and  long  in  the  upper  segment  of  the 
small  intestine,  while  in  the  ileum  they  are  smaller  and  less  dense. 

Intestinal  absorption  is  a  function  of  the  epithelia,  and  is  not 
effected  by  osmosis.  The  gaseous  or  dissolved  food  constituents 
which  have  become  absorbable  are  diffused  in  the  epithelia  of  the 
intestinal  mucosa  and  enter  into  chemical  interrelation  with  their 
protoplasm .  The  protoplasm  itself  undergoes  continuous  disintegra- 
tion and  reintegration,  demanding  a  supply  of  new  material  to  take 
the  place  of  that  which  is  excreted  into  the  blood  or  lymph  vessels 
or  into  the  intestinal  lumen.  Absorption  continues  through  the 
capillaries  and  lacteals.  The  material  in  the  capillaries  is  carried 
to  the  portal  vein,  which  subdivides  into  capillaries  in  the  liver,  the 
capillaries  becoming  reunited  as  hepatic  veins,  anastomosing  with 
the  inferior  vena  cava.  The  lacteals  go  to  the  thoracic  duct,  which 
empties  into  the  left  subclavian  vein. 

Absorption  of  Protein. — Man  and  all  animals  have  the  faculty 
of  rebuilding  protein  from  the  aminoacids  formed  through  the  action 
of  trypsin  and  erepsin.  Of  course  every  animal  species  has  its  own 
specific  protein.  Foreign  protein,  absorbed  in  its  original  form, 
always  acts  as  a  blood  poison;  from  which  it  follows  that  it  is  neces- 
sary for  the  intestine  to  decompose  the  protein  substances  of  a 
given  food  into  simple  and  assimilable  forms.  The  fundamental 
form  is  that  of  aminoacids.  These  aminoacids  are  absorbed  from 
the  small  intestine  and  circulate  in  the  blood  as  such.  Practically 
all  the  nitrogen  derived  from  ingested  and  digested  proteins  is  found 
in  the  portal  stream  in  the  form  of  ultimate  aminoacids.  Absorption 
of  undigested  protein  does  not  normally  occur  to  any  noteworthy 
extent. 

Fat  Absorption. — Absorption  of  fats  can  only  occur  after  the 
fats  have  been  converted  into  liquid  form.  Having  been  emulsi- 
fied, their  surface  is  so  considerably  extended  that  the  fat-splitting 


INTESTINAL  DIGESTION  (>1 

ferments  can  effectively  act  upon  the  small  fat  droplets.  In  this 
process,  neutral  fat  is  split  into  glycerin  and  fatty  acids,  and  the 
latter  are  again  changed  through  the  alkali  of  the  digestive  juices 
into  soluble,  easily  absorbable  fat  soaps.  Simultaneously  the 
glycerin  is  absorbed  and  enters  directly  into  the  absorptive  epi- 
thelial cells,  combining  with  the  fatty  acids  set  free  from  the  soaps 
to  form  neutral  fats,  which  can  be  observed  in  the  deeper  parts  of  the 
intestinal  epithelia  in  the  form  of  minute  droplets.  The  fat  droplets 
emerge  from  the  epithelia  and  pass  into  the  lacteals  and  then  to  the 
thoracic  duct.  Only  the  fats  required  for  further  use  pass  through 
the  thoracic  duct;  they  enter  the  blood  stream  and  are  either  stored 
away  as  adipose  or  oxidized  in  heat  production. 

Carbohydrate  Absorption. — Dextrose,  levulose  and  galactose  are 
absorbed  as  such,  while  glucose  and  sugar  of  milk  are  first  converted 
into  invertose.  The  absorption  of  dextrose  and  maltose  takes  place 
from  hypertonic  as  well  as  hypotonic  solutions.  The  utilization  of 
starch  occurs  more  slowly  than  that  of  pure  sugar,  because  starch 
must  first  be  converted  into  sugar.  Those  starchy  articles  of  food 
which  contain  the  least  cellulose  are  most  easily  digested. 

Absorption  of  Cellulose  and  Hemicellulose. — Cellulose  and  heini- 
cellulose  are  polysaccharids.  Cellulose  is  an  anhydrid  of  dextrose, 
while  hemicelluloses  are  constituents  of  vegetable  cell-walls  which 
belong  neither  to  starch  nor  to  cellulose,  and  can  be  hydrolyzed 
with  dilute  mineral  acids.  Hexosane  (galactan)  and  pentosane 
(arabin,  xylan)  are  the  principal  hemicelluloses,  and  their  sugars 
are  galactose,  arabinose,  and  -xylose.  As  Lohrisch  has  demon- 
strated, both  cellulose  and  hemicellulose  are  digestible  by  man, 
probably  through  a  cytase  of  the  intestinal  juice.  The  normal 
intestine  digests  about  50  per  cent,  of  the  ingested  quantity  of 
cellulose  and  even  a  larger  percentage  of  hemicellulose.  This  is 
shown  by  the  fact  that  the  respiratory  quotient  increases  after 
ingestion  of  cellulose  and  hemicellulose  as  well  as  of  starch  and 
sugar,  only  the  process  is  much  slower  than  after  ingestion  of  pure 
carbohydrates.  Thus  the  process  of  cellulose  digestion  takes  place 
with  the  aid  of  cytase  in  precisely  the  same  wTay  as  the  digestion  of 
starch.  Cellulose  and  hemicellulose  are  transformed  into  their 
respective  sugars  and  absorbed  as  such.  The  physical  and  chemical 
nature  of  these  substances  explains  why  considerably  smaller 
quantities  of  them  are  dissolved  and  absorbed  than  of  the  other 
articles  of  nutrition. 

Absorption  of  Aqueous  and  Saline  Solutions. — Aqueous  and  saline 
solutions  are  chiefly  absorbed  in  the  small  intestine,  both  by  the 
epithelia  and  by  the  intercellular  connective  trabecular,  mostly  in 
a  direction  toward  the  blood  stream. 

Digestion  and  Absorption  in  the  Large  Intestine. — Generally  speak- 
ing, food  is  so  completely  digested  and  assimilated  in  the  small 
intestine  that  only  a  few  remnants  of  it  reach  the  large  intestine. 


62  PHYSIOLOGY  OF  DIGESTION 

Any  portions  of  cellulose  and  hemicellulose  which  have  escaped 
digestion  undergo  transformation  in  the  large  intestine,  notably  in 
the  cecum,  where  with  the  aid  of  the  intestinal  bacteria  they  are 
disintegrated  through  fermentation  into  carbon  dioxid,  methane, 
hydrogen,  and  fluid  fatty  acids  (butyric  and  acetic  acids) .  Absorp- 
tion of  aqueous  and  saline  solutions  occurs  to  a  large  extent  in  the 
large  intestine  as  well  as  in  the  small. 

Intestinal  Movements. — The  muscular  apparatus  of  the  large 
intestine  consists  of  an  exterior  layer  of  longitudinal  fibers  imme- 
diately underneath  the  serosa,  and  an  interior  layer  of  circular 
fibers.  Between  these  muscular  layers  lies  Auerbach's  nerve  plexus. 
In  the  submucosa,  between  the  layer  of  circular  fibers  and  the 
mucous  membrane,  is  Meissner's  nerve  plexus.  Both  these  nerve 
plexuses  are  autonomous  centers.  The  mucous  membrane  has 
besides  a  very  fine  muscular  layer,  the  muscularis  mucosae,  which 
is  supposed  to  have  the  special  function  of  protecting  against 
injury  from  pointed  and  sharp  foreign  bodies  by  means  of  reflex 
movements  controlled  by  Meissner's  plexus. 

The  small  intestine,  when  not  functioning,  is  an  anemic  tube 
without  movement,  and  in  tonic  contraction.  After  the  ingestion 
of  food  the  ansae  of  the  small  intestine  become  hyperemic,  thicker 
and  shorter,  and  execute  various  movements  which  are  differen- 
tiated as  segmenting ,  peristaltic,  and  pendulum. 

The  segmenting  movements  are  continuous  advancing  contrac- 
tions of  the  circular  and  longitudinal  fibers,  occurring  spontaneously 
and  automatically  every  five  or  six'  seconds  as  long  as  there  are  any 
intestinal  contents.  They  effect  a  thorough  mixing  and  kneading 
of  the  contents  without  causing  any  change  in  the  position  of  the 
intestine.  Cannon  calls  this  "rhythmic  segmentation"  and  believes 
that  the  mixing  of  the  food  in  the  small  intestine  is  dependent  upon 
this  movement  rather  than  upon  the  peristaltic  wave.  The  peristal- 
tic wave  forces  the  food  onward.  The  combined  peristaltic  wave 
and  segmentation  brings  every  particle  of  food  into  contact  with 
the  mucous  membrane  of  the  intestine,  at  the  same  time  propelling 
the  contents  onward. 

The  peristaltic  movements  are  brought  about  by  a  local  irritation 
which  causes  a  strong  tonic  contraction  of  the  intestinal  segment 
above  the  place  of  irritation,  while  the  part  below  the  place  of 
irritation  relaxes  for  a  considerable  distance.  This  causes  the 
intestinal  contents,  from  which  the  local  irritation  emanated,  to 
be  driven  downward  for  some  distance.  The  irritation  which  pro- 
duces peristalsis  is  more  intense  in  proportion  as  the  ingested 
food  is  coarse  and  indigestible.  It  naturally  follows  that  food  very 
rich  in  cellulose  promotes  peristalsis  most.  However,  food  rem- 
nants difficult  of  digestion  are  not  the  only  excitants  of  peristalsis; 
the  same  effect  is  brought  about  by  the  decomposition  products 
which  result  from  the  presence  of  intestinal  bacteria  (products  of 


INTESTINAL  DIGESTION  G3 

protein  decomposition  and  fermentative  acids,  formic  acid,  acetic 
acid,  propionic  acid,  butyric  acid,  succinic  acid,  lactic  acid,  etc.). 
Here  again  the  decomposition  products  of  cellulose  in  the  large 
intestine  play  the  most  important  role.  Persons  with  very  good 
cellulose  digestion  frequently  sutler  from  chronic  constipation. 
Among  the  intestinal  gases,  there  are  especially  carbon  dioxid, 
marsh  gas,  and  sulphuretted  hydrogen,  which  cause  marked  peri- 
staltic movements.  Furthermore,  the  influence  of  psychic  excite- 
ment upon  the  intestinal  movements  should  not  be  underrated. 

Pendulum  movements  are  caused  by  exaggerated  peristalsis  in  those 
intestinal  segments  which  are  highly  charged  with  fluid  contents 
and  gas.  In  this  form  of  movement  the  contents  of  these  segments 
are  propelled  downward  with  great  velocity  and  with  loud  bor- 
borygmus  for  rather  a  long  distance,  until  the  impulse  suddenly 
ceases,  only  to  reassert  itself  after  a  more  or  less  prolonged  interval. 
The  sudden  peristaltic  wave,  carrying  the  contents  along  the  whole 
small  intestine,  has  been  called  by  Meltzer  and  Auer  the  "peristaltic 
rush." 

Generally,  there  is  a  decrease  in  the  intensity  of  the  movements 
in  the  small  intestine  from  above  downward;  those  in  the  large 
intestine  are  usually  the  same  as  in  the  small  intestine,  but  slower. 
The  segmenting  movement  in  the  large  intestine  does  not  occur 
so  frequently — only  at  intervals  of  ten  to  fourteen  seconds — but 
is  of  greater  intensity.  The  chyle  usually  passes  through  the  small 
intestine  in  two  to  six  hours,  while  twenty  to  twenty-four  hours, 
and  in  many  persons  a  much  longer  time,  is  required  for  it  to  traverse 
the  shorter  large  intestine. 

Cannon  infers  from  his  observations  on  cats  that  after  the  intes- 
tinal contents  pass  from  the  ileum  into  the  cecum  there  is  a  to-and- 
fro  movement  from  the  beginning  of  the  transverse  colon  to  the 
cecum.  This  antiperistalsis  {anasialsis)  continues  for  some  time. 
The  tonic  ring  in  the  movements  of  the  intestine  is  of  primary 
importance  in  the  study  of  anastalsis.  In  a  state  of  tonus  and  a 
locally  increased  tonic  contraction,  antiperistalsis  of  the  colon  is 
easily  explained.  Antiperistaltic  movements  occur  in  the  cecum, 
the  ascending  colon,  the  proximal  part  of  the  transverse  colon,  and 
the  sigmoid  flexure.  This  antiperistalsis  explains  why  the  intes- 
tinal contents  are  retained  in  the  cecum,  the  ascending  colon,  and 
also  in  the  sigmoid  flexure,  for  a  much  longer  period  than  in  the 
distal  segment  of  the  transverse  colon  and  the  proximal  segment  of 
the  descending  colon. 

The  intestinal  movements  are  controlled  by  Auerbach's  plexus 
through  exciting  impulses  of  the  vagus  and  inhibiting  impulses  of 
the  sympathetic.  Great  excitation  of  the  sympathetic  and  its 
terminations  may  arrest  all  the  intestinal  movements  proceeding 
from  Auerbach's  plexus  and  the  vagus. 

Keith  discovered  a  nodal  tissue  intermediate  between  nerve  and 


64  PHYSIOLOGY  OF  DIGESTION 

muscle  and  interposed  between  Auerbach's  myenteric  plexus  and 
the  smooth  muscle  of  the  intestinal  wall.  This  intermediate  tissue, 
consisting  of  branched  cells  in  direct  connection  with  both  nervous 
and  muscular  elements,  bears  the  same  relation  to  the  intestinal 
musculature  as  the  primitive  nodes  and  conducting  tissues  of  the 
heart  bear  to  the  auricular  and  ventricular  muscular  masses.  It 
possesses  two  distinct  functions:  one,  the  initiation  and  regulation 
of  the  muscular  contractions  in  the  segment  of  the  intestine  which 
it  controls;  the  other,  the  power  of  conducting  impulses  which  lead 
to  the  forward  propulsion  of  the  intestinal  contents.  Keith  found 
that  food  passing  along  the  alimentary  tract  is  propelled  through 
a  series  of  zones  or  segments  furnished  with  their  own  pacemaker. 
To  obtain  an  orderly  propulsion  of  the  food  along  the  whole  length 
of  the  alimentary  canal,  these  various  rhythmic  zones  must  be 
closely  coordinated  in  their  action;  and  this  coordination  means  a 
complicated  system  of  reflexes  (see  pages  561  and  696). 

It  is  now  believed  that  the  entire  digestive  tract  is  supplied  with 
extrinsic  nerves  which  when  stimulated  cause  increased  tone  and 
the  destruction  of  which  results  in  loss  of  tone.  Cannon  is  con- 
vinced that  this  tonus  is  fundamental.  It  supplies  the  resiliency 
that  causes  the  state  of  tension  when  the  canal  is  filled  or  establishes 
the  state  of  tension  when  the  canal  is  only  partly  filled.  This  state 
of  tension  is  indispensable  for  the  contraction  of  viscera  which  are 
walled  with  smooth  muscle  holding  a  nerve  net.  Hunger  contrac- 
tions have  no  connection  with  the  normal  tonus  of  the  stomach; 
they  are  initiated  and  sustained  by  the  impulses  of  independent 
neurons  in  the  central  nervous  system,  and  when  these  neurons 
become  fatigued  through  prolonged  action  the  hunger  contractions 
of  the  stomach  cease.  These  contractions  are  normally  continuous 
in  infants ;  while  in  adults,  even  though  food  be  denied,  they  alternate 
with  quiescent  periods. 

As  a  rule  the  chyme,  after  having  left  the  stomach,  passes  through 
the  small  intestine  in  two  or  three  hours;  under  normal  conditions 
the  transverse  colon  may  contain  the  first  food  remnants  in  four 
hours,  and  the  sigmoid  flexure  may  be  filled  in  six  hours.  On  the 
other  hand,  the  fecal  mass  is  often  retained  for  hours  in  the  splenic 
flexure.  The  movement  of  the  fecal  mass  has  been  thoroughly 
studied  by  means  of  the  Roentgen  ray  (see  Chapter  V).  In  the 
cecum  and  ascending  colon  the  intestinal  contents  are  still  soft  and 
massy,  while  farther  on  they  are  of  a  more  formed  consistence. 
The  sigmoid  flexure  is  the  real  fecal  reservoir.  The  presence  of 
fecal  matter  in  the  rectum  causes  a  sensation  of  tenesmus,  and  the 
sensitiveness  of  the  rectum  is  so  pronounced  that  the  presence  of 
gases  and  of  solid  or  fluid  feces  can  be  very  accurately  distinguished. 

The  closure  of  the  rectum  is  effected  by  the  sphincter  ani  inter- 
nus  (smooth  muscle  fibers)  and  externus  (transversely  striated 
fibers).     Both  sphincters  are  continually  in  a  state  of  tonic  con- 


INTESTINAL  DIGESTION  65 

traction,  which  may  be  increased  or  inhibited.  They  possess  their 
own  automatic  nerve  center,  but  are  subordinated  to  other  centers 
in  the  spinal  column  and  cerebrum.  If  a  defecation  is  desired, 
the  cerebrum  effects  an  inhibition  of  the  sphincteric  contraction, 
upon  which  the  fecal  column  is  propelled  downward. 

Law  of  Contrary  Innervation. — This  law,  as  laid  down  by  Meltzer, 
is  manifest  in  all  functions  of  the  animal  body.  Stimulation  or 
contraction  in  any  part  of  the  digestive  canal  induces  inhibition  or 
relaxation  of  the  part  just  below.  Contraction  of  the  lower  parts 
of  the  esophagus  and  of  the  cardia  is  inhibited  as  soon  as  the  upper 
end  of  the  canal  of  deglutition  begins  to  contract.  Local  stimula- 
tion of  a  segment  of  the  intestine  causes  contraction  at  the  point 
of  stimulation  and  relaxation  of  the  part  below.  This  phenomenon 
has  been  called  by  some  authors  the  law  of  the  intestine,  but  it  is 
now  known  to  be  a  general  law  of  contrary  innervation. 

Feces. — The  feces  which  are  finally  evacuated  per  rectum  as  an 
end-product  of  digestion  consist  partly  of  food  remnants,  partly 
of  remnants  of  the  secretions  of  digestion,  with  additions  of  mucus, 
bacteria,  intestinal  epithelia,  and  excretory  products  of  the  large 
intestine.  As  is  well  known,  there  are  also  hunger  feces  in  which 
nitrogen  and  ash  constituents,  especially  lime,  phosphates,  mag- 
nesium, and  even  iron,  are  excreted  into  the  lumen  of  the  intestine. 
The  time  for  the  evacuation  of  the  feces  after  a  given  meal  varies 
from  eight  to  thirty  hours.  It  is  important  to  respond  as  soon  as 
there  is  a  desire  for  defecation.  If  the  endeavor  is  not  made,  the 
rectum  soon  becomes  accustomed  to  the  presence  of  feces  and  fails 
in  sensation  for  desire. 

For  further  observations  on  the  subject  of  feces,  Chapter  IV  on 
Examination  of  the  Feces  should  be  consulted. 


CHAPTER  II. 
EXAMINATION  OF  THE  STOMACH  CONTENTS. 

Examination  of  material  obtained  from  the  fasting  stomach  is  one 
of  the  most  important  diagnostic  aids  in  ascertaining  the  nature  and 
extent  of  pathologic  conditions  of  the  stomach. 

The  presence  of  food  remnants  in  large  quantities  from  the  last 
or  from  a  preceding  meal,  especially  if  sour-smelling,  points  to  a 
disturbance  of  gastric  motility.  If  the  quantity  of  gastric  juice 
which  may  be  removed  from  the  fasting  stomach  constantly  exceeds 
100  Cc,  a  condition  known  as  gastrosuccorrhea  (Reichmann's  dis- 
ease), gastrorrhea,  hypersecretion,  or  gastrochylorrhea,  is  present. 
According  to  recent  investigations,  it  is  highly  probable  that  gas- 
trochylorrhea is  a  sequel  to  disturbance  of  the  motor  functions 
of  the  stomach.  A  small  amount  of  mucus  and  saliva  may  be 
found. in  the  normal  fasting  stomach,  its  viscidity  being  observed 
in  pouring  from  one  vessel  to  another.  Numerous  mucin  bodies 
and  epithelial  cells  are  seen  upon  microscopic  examination.  The 
presence  of  mucus  and  saliva  in  the  fasting  stomach  may  be  due 
to  stomatitis,  pharyngitis,  ptyalism,  or  pathologic  conditions  affect- 
ing the  glandular  portion  of  the  stomach. 

Bile  may  regurgitate  into  the  stomach  from  the  duodenum. 
When  it  has  been  long  in  the  stomach  it  undergoes  change,  its 
bilirubin  becoming  biliverdin,  so  that  the  fluid  takes  on  a  yellowish 
or  greenish  color.  Bile  does  not  interfere  with  the  peptic  activity 
of  the  gastric  glands,  except  that,  like  every  protein  body,  it  has  a 
strong  affinity  for  the  acid  of  the  stomach.  Sometimes  in  the 
fasting  stomach  a  mixture  of  bile,  pancreatic  juice,  and  perhaps 
succus  entericus  is  found — without  special  pathologic  significance  if 
the  quantity  is  small. 

Blood  is  found  in  the  stomach  under  such  conditions  as  hemor- 
rhage from  gastric  ulcer,  irritation  of  the  pathologic  mucosa  upon 
the  passing  of  a  stomach  tube,  or  vigorous  movements  caused  by 
expression  of  stomach  contents.  Hemorrhages  may  originate  in 
the  mouth,  esophagus,  pharynx,  nasal  cavity,  or  lungs.  Hemoptysis 
and  hematemesis  may  exist  simultaneously;  when,  however,  only 
one  is  present,  it  is  not  a  difficult  matter  to  distinguish  its  source. 
Slight  hemorrhages,  with  admixture  of  mucus,  are  significant  only 
when  found  upon  repeated  examinations. 

Pus,  according  to  recent  investigators,  is  frequently  found  in 
stomach  contents;  it  is  always  pathologic.    It  is  often  found  in 


TEST  MEALS  67 

cases  of  ulcerating  carcinoma.  It  is  easily  recognized,  even  macro- 
scopically,  in  such  cases,  by  the  foul-smelling  yellowish-green  and 
occasionally  blood-stained  masses. 


TEST  MEALS. 

The  secretion  of  gastric  juice  starts  almost  as  soon  as  the  food 
enters  the  stomach  and  continues  until  it  enters  the  duodenum. 
The  investigations  of  Pawlow  show  that  it  starts,  as  a  result  of 
anticipation,  even  before  the  food  reaches  the  stomach  (psychic 
secretion).  During  the  latter  period  of  gastric  digestion  the  secre- 
tion normally  decreases,  for  which  reason  the  results  of  analytic 
examination  of  the  gastric  contents  are  subject  to  variation.  The 
first  hydrochloric  acid  secreted  by  the  stomach  unites  with  all 
the  protein  and  salts  to  form  combined  aciis.  Only  after  all  these 
affinities  have  been  satisfied  can  we  find  free  hydrochloric  acid. 
If  a  meal  consists  of  large  quantities  of  protein,  it  is  obvious  that 
free  hydrochloric  acid  will  appear  later  than  if  the  meal  consisted 
in  larger  proportion  of  carbohydrates.  A  test  meal  should  contain 
all  the  ingredients  of  an  ordinary  meal.  In  order  to  make  a  study 
of  the  secretory  function  of  the  stomach  we  must  have  a  standard 
test  meal  of  definite  and  constant  composition.  It  is  customary  to 
give  test  meals  in  the  morning,  when  the  stomach  is  most  likely  to 
be  empty;  occasionally,  however,  they  are  given  at  noon  or  in  the 
evening,  according  to  the  purpose  in  view. 

Ewald-Boas'  Test  Breakfast. — Ewald-Boas'  test  breakfast  consists 
of  a  roll  or  two  slices  of  white  bread  without  butter  and  two  small 
cups  (300  to  400  Cc.)  of  water  or  weak  tea  without  cream  or  sugar. 
The  patient  should  thoroughly  masticate  the  bread  or  roll.  The 
stomach  contents  should  be  removed  in  one  hour,  since  digestion 
is  at  its  height  at  this  time.  This  test  breakfast  contains  protein, 
sugar,  starches,  non-nitrogenous  extractives,  and  salts.  It  will  thus 
be  seen  that  the  stomach  is  offered  all  the  usual  ingredients  of  a 
meal,  with  the  advantage  that  the  whole  is  liquefied  in  a  very 
short  time  and  so  modified  that  passage  of  the  contents  through  the 
stomach  tube  is  not  hindered,  as  might  be  the  case  if  more  solid 
food  were  taken.  This  test  breakfast,  while  suitable  for  routine 
examination,  has  the  disadvantage  of  introducing  into  the  stomach 
a  variable  amount  of  lactic  acid  as  well  as  numerous  yeast  cells  with 
the  bread. 

Boas'  Test  Breakfast. — Boas'  test  breakfast  consists  of  a  table- 
spoonful  of  rolled  oats  in  a  quart  of  water,  reduced  to  one  pint  by 
boiling.  A  pinch  of  salt  is  added  to  make  it  more  palatable  to  the 
patient.  This  meal,  inasmuch  as  it  does  not  contain  lactic  acid, 
is  usually  given  when  detection  of  lactic  acid  is  important,  as  in 
cases  of  suspected  carcinoma. 


68  EXAMINATION  OF  THE  STOMACH  CONTENTS 

Riegel  Test  Dinner. — At  noon  the  patient  is  given  a  meal  consisting 
of  beef  broth,  150  to  180  Cc.  (5  to  6  ounces)  of  beefsteak,  60  Gm. 
(2  ounces)  of  mashed  potatoes,  and  a  roll  of  white  bread.  The 
stomach  contents  are  removed  in  from  three  to  four  hours  and 
examined.  The  advantage  of  this  test  meal  is  the  opportunity 
it  affords  to  note  the  degree  of  digestibility  of  starches  and  proteins. 
Fleiner's  test  meal  is  similar. 

MACROSCOPIC  EXAMINATION  OF  STOMACH  CONTENTS. 

Having  withdrawn  the  test  meal  at  the  allotted  time,  the  physician 
should  carefully  inspect  the  appearance  and  note  the  quantity  and 
odor  of  the  material.  After  the  stomach  tube  is  introduced,  as 
stated  below,  there  are  two  methods  of  obtaining  the  stomach  con- 
tents: (1)  The  expression  method,  and  (2)  aspiration  by  means  of 
some  suction  apparatus. 

Methods  for  Obtaining  Stomach  Contents. — Expression  Method. — 
The  first  method  is  the  simplest  and  easiest  at  our  command,  and 
the  stomach  tube  itself  is  the  only  instrument  necessary.  The 
tube  being  in  the  stomach,  the  patient  is  instructed  to  take  a  deep 
inspiration,  to  hold  his  breath,  and  bear  down  with  his  abdominal 
muscles,  when  the  gastric  contents  will  pour  out  from  the  end  of  the 
tube  into  a  tumbler  held  for  their  reception.  Sometimes  coughing 
or  moving  the  tube  a  little  will  produce  a  gagging  sensation,  and 
this  induces  the  abdominal  pressure  that  forces  out  the  stomach 
contents.  Should  nothing  come  through  the  tube,  it  may  be 
assumed  that  the  stomach  is  empty.  In  removing  the  tube  it  is 
well  to  cover  the  end  snugly  with  the  finger,  to  prevent  the  escape 
of  as  much  of  the  stomach  contents  as  the  tube  contains,  thereby 
adding  so  much  more  to  the  quantity  for  examination  and  at  the 
same  time  avoiding  a  "muss." 

Aspiration  Method. — For  removing  gastric  contents  by  the  second 
method,  almost -any  instrument  that  will  create  a  vacuum  may  be 
employed.  The  so-called  "stomach  pump"  has  been  used,  but  it 
has  been  found  that  sometimes,  even  in  its  careful  use,  pieces  of 
gastric  mucous  membrane  are  detached — drawn  into  the  eye  of  the 
tube.  The  aspirator  bulb  of  Ewald  consists  of  a  ten-ounce  Politzer 
bag,  with  a  large-sized  hard-rubber  tip  over  which  the  stomach  tube 
can  be  adjusted.  The  stomach  tube  having  been  placed  in  position 
in  the  stomach,  the  air  is  forced  out  of  the  bag  or  bulb,  and  the 
tube  is  attached;  then,  allowing  the  bag  to  expand,  the  stomach 
contents  are  aspirated.  Aspirating  bottles  with  stopcocks  and 
other  complicated  attachments  have  been  devised  for  the  removing 
of  the  stomach  contents,  but  such  apparatus  is  really  unnecessary. 

I  have  an  improved  stomach  tube  which  I  find  very  practical 
(Fig.  1).  It  is  made  of  soft  rubber,  but,  though  readily  flexible,  is 
nevertheless  rigid  enough,  owing  to  its  size  and  the  thickness  of  its 


MACROSCOPIC  EXAMINATION  OF  STOMACH  CONTENTS    69 

walls,  to  avoid  all  danger  of  coiling  or  kinking  in  the  pharynx  or 
esophagus.  It  is  84  cm.  (32  inches)  long,  rounded  and  solid  at  its 
lower  end,  with  two  lateral  openings,  one  about  2  em.  (three-fourths 
inch)  from  the  end,  the  other  just  above  it  on  the  opposite  side. 
These  openings  run  obliquely  upward,  and  have  no  sharp  edges;  the 
edges  have  been  smoothed  away  in  molding  (velvet-catheter  eye), 


Fig.  1. — Author's  improved  stomach  tube  and  bulb. 

so  that  traumatism  or  other  injury  to  the  mucous  membrane  from 
contact  is  impossible.  The  openings  are  large,  rendering  aspiration 
of  the  stomach  contents  easy.  The  lower  end  is  made  solid  so  that 
no  particles  of  food  can  accumulate  there,  as  frequently  occurs  in 
tubes  with  a  terminal  cul-de-sac.  The  main  distinguishing  feature 
of  this  stomach  tube  is  that  the  closed,  smooth,  rounded  end  con- 
tains a  heavy  piece  of  lead.    This  weighted  end  facilitates  the  pas- 


70 


EXAMINATION  OF  THE  STOMACH  CONTENTS 


sage  of  the  tube  down  the  esophagus  without  any  effort  on  the  part 
of  the  patient  (Fig.  2).  Most  patients  regard  the  swallowing  of  a 
formidable-looking  stomach  tube  as  somewhat  of  an  ordeal,  but 
there  is  no  need  of  swallowing  or  "  gulping"  when  this  tube  is  used. 
In  the  use  of  this  tube,  when  the  stomach  contents  are  to  be 
aspirated,  the  patient  should  sit  upright,  with  his  head  bent  slightly- 
forward  and  held  absolutely  motionless.  He  is  instructed  to  breathe 
slowly  and  regularly  through  the  nose  and  to  pay  absolutely  no 
attention  to  what  is  about  to  take  place. 
The  physician,  standing  in  front  of  the 
patient,  dips  the  free  end  of  the  tube  in  cold 
water  and  passes  it  directly  to  the  posterior 
pharyngeal  wall,  which  guides  it  downward 
toward  the  entrance  of  the  esophagus.  The 
weighted  end  carries  the  tube  to  the  laryngo- 
pharyngeal opening,  where  it  stops.  A  gentle 
push  on  the  tube  is  now  all  that  is  necessary 
to  carry  it  over  the  cricoid  cartilage  down 
the  esophagus  into  the  stomach,  provided 


I    I 


l     I 


J  — 


\ 


Fig.  2. — a,  Lower  end  of  author's  stomach  tube; 
b,  sectional  view;  c,  lead;  d,  solid  rubber. 


Fig.  3. — Einhorn's  stom- 
ach bucket. 


there  is  no  obstruction  in  the  esophagus.  It  is  unnecessary  to  tell 
the  patient  to  swallow,  except  in  rare  instances  when  the  muscles 
of  the  neck  contract  spasmodically,  holding  the  tube  tight.  Many 
times  the  tube  passes  so  quickly  into  the  stomach  that  it  is  advis- 
able to  move  it  backward  and  forward  to  irritate  the  throat  and 
induce  gagging,  which  greatly  assists  the  aspiration  process. 

Before  passing  the  tube,  I  have  the  external  end  connected  with 
an  evacuating  bulb  by  means  of  a  short  piece  of  glass  tubing  and  a 
soft-rubber  tube  about  16  cm.  (6  inches)  in  length.    The  bulb  is 


MACROSCOPIC  EXAMINATION  OF  STOMACH  CONTENTS    71 

then  compressed,  and  a  bend  in  the  soft-rubber  tube  held  with  the 
thumb  and  finger  of  the  left  hand  prevents  it  from  filling  with  air. 
As  soon  as  the  tube  reaches  the  stomach  the  soft-rubber  connecting 
tube  is  released,  and  the  bulb,  in  recovering  its  natural  expanded 
form,  aspirates  sufficient  gastric  contents  for  analytic  purposes 
(Fig.  1). 

Should  lavage  be  desired,  it  can  be  readily  and  safely  carried  out 
with  the  tube  and  the  evacuating  bulb.  The  food  residue  in  the 
stomach  is  aspirated  as  completely  as  possible  with  the  empty  bulb ; 
the  bulb  is  then  detached,  filled  with  water,  reattached,  and  slowly 
compressed  until  all  the  water  has  been  introduced  into  the  stomach. 
Then,  by  the  mere  act  of  releasing  the  pressure  on  the  bulb,  the  water 
is  withdrawn  by  aspiration  from  the  stomach.  This  procedure  is 
repeated  with  a  second  bulbful,  and  as  often  as  may  be  necessary 
until  the  water  returns  perfectly  clear. 

In  dealing  wTith  the  difficulties  the  physician  encounters  in 
removing  the  stomach  contents  of  hypersensitive  patients,  I  find  that 
nausea  and  retching  is  one  of  the  greatest  obstacles  to  the  success- 
ful performance  of  the  task.  These  patients  become  nauseated 
at  the  mere  sight  or  thought  of  the  stomach  tube.  The  very  act 
of  cocainizing  the  posterior  or  faucial  wall,  which  some  authors 
advocate  to  overcome  this  unpleasant  feature  of  the  proceedings, 
conduces  to  the  production  of  retching  and  is  by  no  means  willingly 
tolerated  by  this  class  of  patients.  Some  authors,  indeed,  go  so 
far  as  to  advise  abandoning  any  attempt  at  introducing  the  tube 
in  patients  with  pronounced  retching  tendencies,  dispensing  with 
this  method  of  examination  altogether  rather  than  subject  such 
patients  to  the  ordeal.  It  is  evident  that  the  apprehensions  of 
sensitive  patients  cannot  be  entirely  allayed  by  persuasion,  tact, 
or  skill.  The  question  then  arises :  Can  the  unavoidable  unpleas- 
antness and  inconvenience  be  shortened,  and  how?  The  answer 
is  that  it  can  be  shortened  and  minimized  by  introducing  the  tube 
less  deeply — in  fact  by  not  allowing  it  to  enter  the  stomach  at  all, 
and  yet  obtaining  a  quantity  of  gastric  contents  sufficient  for 
chemical  and  microscopical  analysis. 

Regurgitation. — In  devising  this  process,1 1  have  been  guided  by  a 
consideration  of  the  anatomic  fact  that  the  lower  third  of  the 
esophagus  is  normally  distended,  forming  a  continuous  open  lumen. 
As  soon  as  the  stomach  tube  reaches  that  part,  the  cardia,  following 
the  law  of  contrary  innervation,  becomes  relaxed,  and  as  a  result 
the  gagging  and  retching  of  the  patient  induces  a  regurgitation  of 
some  of  the  gastric  contents  into  the  esophagus,  where  the  fenes- 
trated end  of  the  stomach  tube  is  ready  to  receive  it,  and  whence  it  is 
promptly  aspirated  by  the  atmospheric  vacuum  action  of  the 
terminal  rubber  bulb  (Fig.  1).     In  the  mere  act  of  passing  beyond 

1  Aaron,  Charles  D.:  A  Simplified  Method  of  Aspirating  Gastric  Contents  in 
Hypersensitive  Patients,  Michigan  State  Medical  Journal,  September,  1918. 


72  EXAMINATION  OF  THE  STOMACH  CONTENTS 

the  tracheal  bifurcation  the  tube  causes  the  contents  of  the  stomach, 
however  low,  to  regurgitate  into  the  esophagus  through  the  relaxed 
cardia  and  meet  the  receptive  stomach  tube  half-way.  Thus  it  is 
quite  unnecessary  for  the  tube  to  enter  the  stomach,  and  the  greater 
the  gagging  and  retching  of  the  patient  the  easier  it  is  to  obtain  a 
sample  of  the  gastric  contents. 

When  the  tube  is  not  in  use  it  should  never  be  coiled,  but  laid  out 
straight.  If  this  precaution  is  observed,  the  original  shape  of  the 
tube  will  be  maintained  so  that  it  will  glide  easily  through  the 
esophagus  into  the  stomach  as  described. 

Einhorn  has  devised  a  stomach  bucket  to  remove  the  stomach 
contents.  It  consists  of  a  small  capsule-shaped  vessel  (Fig.  3)  made 
of  silver  (If  cm.  long,  f  cm.  wide),  open  at  the  top  and  for  a  short 
distance  down  the  side.  The  opening  is  surmounted  by  an  arch,  to 
which  a  silk  thread  is  tied,  and  a  knot  is  made  16  inches  from  the 
attachment.  In  order  to  secure  a  sample  of  the  stomach  contents, 
the  bucket  is  first  dipped  in  lukewarm  water  (filled  and  emptied)  to 
facilitate  filling  when  in  the  stomach;  the  patient  is  asked  to 'open 
his  mouth  wide,  and  the  bucket  is  placed  on  the  root  of  the  tongue 
(almost  in  the  pharynx);  the  patient  is  then  instructed  to  per- 
form the  act  of  swallowing,  and  within  a  few  seconds  the  bucket 
enters  the  stomach.  It  is  left  there  for  five  minutes  and  then 
withdrawn.  During  the  withdrawal  of  the  apparatus,  resistance 
is  usually  felt  at  the  introitus  esophagi.  To  overcome  this  difficulty 
the  patient  is  again  instructed  to  swallow,  by  which  act  the  larynx 
is  pushed  forward  and  upward  in  such  a  manner  as  to  free  the  pas- 
sage, when  the  bucket  can  be  easily  withdrawn.  If  the  stomach 
was  not  empty,  the  bucket  returns  with  gastric  contents  sufficient 
for  the  making  of  various  important  tests. 

Inspection  of  Stomach  Contents. — By  inspection  one  should  dis- 
tinguish between  absolutely  undigested,  partially  digested,  and  well 
digested  contents.  It  is  also  possible  to  distinguish  by  inspection 
between  carbohydrate  and  protein  digestion.  Absolutely  undi- 
gested food  masses  are  found  in  advanced  cases  of  gastric  catarrh, 
in  atrophic  conditions  of  the  gastric  mucous  membrane,  and  like- 
wise in  achylia  gastrica.  The  presence  of  undigested  food  points 
also  to  marked  secretory  disturbance.  In  such  conditions  the 
appearance  of  the  test  meal  after  removal  resembles  that  of  a  mix- 
ture of  bread  and  water  before  ingestion.  The  absence  of  peptic 
digestion  is  ascertained  by  the  clearness  of  the  filtrate.  By  inspec- 
tion the  presence  of  blood,  mucus,  bile,  or  intestinal  juices,  and 
occasionally  pus,  animal  parasites,  and  fragments  from  the  gastric 
mucosa,  may  be  detected.  In  cases  characterized  by  marked 
gastric  retention,  the  stomach  contents  when  placed  in  a  vessel  and 
allowed  to  stand  for  a  few  minutes  are  sometimes  observed  to  be 
in  three  separate  layers :  the  upper  consists  of  mucus,  or  undigested 
food  particles  which  have  undergone  fermentation;  the  next,  which 


MACROSCOPIC  EXAMIXATION  OF  STOMACH  CONTENTS     7Z 

is  the  largest,  of  fluid;  while  that  on  the  bottom  of  the  vessel  consists 
of  chyme.  This  is  the  condition  found  in  abnormal  gastric  fermen- 
tation and  extreme  motor  insufficiency  (dilatation). 

The  filtrate  of  the  entire  contents  of  the  normal  stomach,  evacu- 
ated exactly  one  hour  after  a  test  breakfast,  measures  20  to  50 
Cc.  There  may  be  much  less  than  this,  or  the  stomach  may  be 
entirely  empty;  if  so,  the  condition  is  what  has  been  designated 
hypermotility  or  hyperkinesis,  found  in  organic  and  nervous  gastric- 
affections,  such  as  chronic  gastritis,  achylia  gastriea,  bulimia,  and 
whenever  there  is  insufficiency  of  the  pylorus.  On  the  other  hand,  if 
remnants  of  the  preceding  meal  are  constantly  found  in  the  stomach 
contents  in  the  morning,  the  finding  is  indicative  of  impairment  in 
gastric  motility,  the  degree  of  which  can  be  ascertained  only  by 
repeated  examinations  of  the  stomach  contents. 

Determination  of  Gastric  Juice. — The  method  of  Mathieu  and 
Remond  is  commonly  used  to  determine  the  total  amount  of  gastric 
juice  secreted.  The  gastric  contents  are  removed  as  completely 
as  possible  at  the  usual  interval  after  an  Ewald  test  breakfast. 
Water,  200  Cc.  (|  pint),  is  then  poured  into  the  stomach  through 
the  stomach  tube  and  thoroughly  mixed  with  the  remnants  of  the 
test  breakfast  in  the  stomach  by  moving  the  funnel  up  and  down, 
as  well  as  by  pressure  upon  the  stomach.  As  much  as  possible  of 
this  mixture  is  then  evacuated  in  a  separate  receptacle,  and  the 
clinician  proceeds  to  ascertain  the  acidity  of  the  undiluted  as  well 
as  that  of  the  diluted  stomach  contents.  From  these  data,  conclu- 
sions may  be  drawn  as  to  the  degree  of  dilution  and  the  amount  of 
the  residual  gastric  contents. 

Mathieu  endeavors  to  ascertain  the  total  stomach  contents  by 
the  following  formula : 

a  =  the  acidity  of  the  undiluted  gastric  contents. 

b  =  the  acidity  of  the  diluted  gastric  contents. 

x  =  the  amount  of  the  test  meal  remaining  in  the  stomach  after  the  first 

extraction. 

200  Cc.  =  the  amount  of  water  introduced  into  the  stomach  for  diluting. 

Then 

a  :  b  :  :  (x  +  200)  :  x 

ax  =b(x  +  200) 

ax  -  bx  =  200  b 

200  b 

x  =   h 

a — o 

In  ascertaining  the  acidity  of  the  stomach  contents,  it  is  necessary 
to  determine  the  total  available  acidity  rather  than  the  mere  degree 
of  acidity. 

Color. — Gastric  juice  is  a  colorless  liquid,  though  at  times  faintly 
opaque.  It  may  vary,  however,  with  the  color  of  food  taken. 
Coffee  or  particles  of  toasted  bread  will  lend  a  distinctly  brownish 
coloration,  while  meat  will  tend  to  discolor  the  juice  red.  A  distinct 
red  color  may  also  be  due  to  the  presence  of  blood,  which  grows 
darker  the  longer  the  blood  remains  in  the  stomach.     The  color  of 


74  EXAMINATION  OF  THE  STOMACH  CONTENTS 

the  gastric  contents  may  be  either  yellow  or  green,  due  to  the 
presence  of  bilirubin  or  biliverdin,  biliary  pigments  which  may  be 
detected  by  the  tests  for  bile  in  the  urine.  A  brownish-black 
coloration  and  fetid  odor  of  the  stomach  contents  points  to  intestinal 
obstruction  below  the  duodenum. 

Odor. — The  odor  of  normal  gastric  juice  is  slightly  sour.  It  is 
offensive  when  the  gastric  juice  is  mixed  with  materials  from  the 
intestinal  canal.  In  the  vomitus  of  uremia  there  is  often  a  distinct 
odor  of  ammonia;  an  alcoholic  odor  is  present  in  alcoholic  intoxi- 
cation. Stagnation  of  gastric  contents  gives  rise  to  an  intensely 
strong  odor. 

Consistency. — Usually  watery  in  character,  the  normal  stomach 
contents  vary  with  the  character  of  the  extraneous  material  com- 
posing them.  In  catarrhal  gastritis  or  in  cases  marked  by  sub- 
acidity,  there  may  be  present  after  a  test  meal  so  much  tough, 
slimy  mucoid  material  as  to  render  filtering  of  the  stomach  contents 
impossible. 

The  stomach  is  practically  never  empty,  always  containing  a 
certain  quantity  of  fluid,  normally  acid  in  reaction,  in  amounts 
of  not  less  than  ten  or  more  than  a  hundred  cubic  centimeters. 


CHEMICAL  EXAMINATION  OF  STOMACH  CONTENTS. 

Chemical  examination  of  gastric  contents  consists  in  the  use  of 
reagents  to  determine  the  actual  state  of  digestion,  so  that  by 
comparing  it  with  normal  physiologic  digestion  one  may  obtain 
information  in  regard  to  any  functional  disturbances  or  changes 
present.  These  examinations  should  be  made  as  frequently  as 
may  be  necessary  to  enable  the  clinician  to  form  a  correct  estimate 
of  the  condition  of  the  gastric  function;  it  is  only  in  rare  cases  that 
positive  results  can  be  obtained  from  a  single  examination. 

Apparatus. — The  special  apparatus  required  for  the  analytic 
work  is  very  simple  (Fig.  4) . 

In  a  complete  chemical  analysis  the  following  tests  should  be  made : 

Tests.  Reagents. 

1.  Reaction Litmus. 

2.  Hydrochloric  acid      .      .      .  Gunzburg  (see  p.  76). 

3.  Total  acidity Phenolphthalein  (see  p.  79). 

4.  Free  hydrochloric  acid    .      .  Dimethylamidoazobenzol  (see  p.  80). 

5.  Combined  hydrochloric  acid  Alizarin  (see  p.  81). 

6.  Lactic  acid Uffelmann  (see  p.  82). 

7.  Pepsin Mett  (see  p.  84). 

8.  Rennin Calcium  chloride  (see  p.  84). 

9.  Propeptone Copper  sulphate  (see  p.  84). 

10.  Peptone Sodium  chlorid  (see  p.  84). 

11.  Dextrin Lugol  solution  (see  p.  85). 

12.  Erythrodextrin     ....  Lugol  solution  (see  p.  85). 

13.  Achroodextrrn      ....  Lugol  solution  (see  p.  85). 

14.  Maltose Fehling  solution. 


CHEMICAL  EXAMINATION  OF  STOMACH  CONTENTS      75 

Determination  of  Reaction. — After  macroscopic  examination   of 

the  stomach  contents,  a  portion  should  be  filtered  and  the  filtrate 
tested  with  litmus  paper,  in  order  to  ascertain  the  reaction,  which 
may  be  acid,  alkaline,  amphoteric,  or  neutral.  If  the  reaction  is 
found  to  be  acid,  the  next  step  is  to  ascertain  the  presence  of  free 
hydrochloric  acid.  This  is  done  by  means  of  Congo  red.  Congo 
red  was  introduced  into  practice  and  recommended  in  the  form  of 
Congo  paper,  as  a  reagent  for  free  hydrochloric  acid.  Congo  red 
in  solution  is,  however,  more  sensitive  than  Congo  paper.  The 
solution  is  prepared  by  dissolving  1  gram  of  the  powdered  Congo 
red  in  100  Cc.  of  water.  By  the  use  of  the  solution  0.0009  per 
cent,  of  hydrochloric  acid  may  be  detected,  while  the  paper  does 
not  react  unless  0.01  per  cent,  of  acid  is  present.  Congo  red  paper 
consists  simply  of  filter  paper  saturated  with  an  alcoholic  solution 
of  Congo  red  and  allowed  to  dry.     The  color  changes  from  red 


Fig.  4. — Necessary  apparatus  for  making  analysis  of  stomach  contents:  A,  glass 
tumbler  for  holding  stomach  contents;  B,  filter  paper;  C,  glass  funnel;  D,  sedimen- 
tation glass;  E,  gastric  filtrate;  F,  F,  graduated  pipets,  holding  5  Cc;  G,  porcelain 
spoon;  H,  beaker;  I,  alcohol  lamp;  J,  buret  for  titrating  with  one-tenth  normal 
sodium  hydrate  solution;  K,  buret  stand. 


to  blue  on  contact  with  free  hydrochloric  acid.  The  test  establishes 
the  presence  of  free  mineral  acids  only.  High  acidity  from  free 
lactic  acid  in  the  stomach  may,  however,  give  a  distinct  reaction. 
The  test  is  of  value  for  the  detection  of  free  hydrochloric  acid,  since 
this  is  ordinarily  the  only  mineral  acid  to  be  found  in  the  stomach 
contents. 

Dimethylamidoazobenzol  Test.- — This  test  depends  upon  the  color- 
ation which  a  0.5-per-cent.  alcoholic  solution  of  dimethylamido- 
azobenzol produces  when  treated  with  gastric  juice  containing  free 
hydrochloric  acid.  To  make  the  test,  a  few  cubic  centimeters  of 
filtrate  from  the  stomach  contents  after  the  test  breakfast  are  placed 
in  a  porcelain  spoon  or  dish,  and  one  to  two  drops  of  the  dimethyl- 
amidoazobenzol solution  added.  A  carmin  red  color  results  when 
free  hydrochloric  acid  is  present  (Plate  II,  Fig.  1) .  This  reagent,  does 
not  react  to  organic  acids  unless  they  are  present  in  amount  over 


76  EXAMINATION  OF  THE  STOMACH  CONTENTS 

0.5  per  cent.  The  proportion  of  free  hydrochloric  acid  present 
may  be  determined  by  the  intensity  of  coloration  when  the  reagent 
is  added,  for  as  small  a  proportion  as  one  part  to  fifty  thousand,  or 
0.002  per  cent.,  gives  the  color  reaction. 

From  a  clinical  point  of  view  it  is  of  the  utmost  importance  to 
determine  the  presence  or  absence  of  hydrochloric  acid.  After  this 
has  been  determined,  it  must  be  ascertained  whether  the  secretion 
is  increased  or  decreased.  When  free  hydrochloric  acid  is  found  to 
be  present,  it  is  unnecessary  to  test  for  pepsin  or  pepsinogen,  since 
this  ferment  is  always  present  when  free  hydrochloric  acid  can  be 
demonstrated.  When,  however,  this  acid  is  absent,  we  may  still 
have  a  secretion  of  pepsinogen. 

For  the  detection  of  free  hydrochloric  acid  the  Gunzburg  test  is 
perhaps  the  most  reliable. 

Giinzburg's  Test. — Giinzburg's,  or  the  phloroglucin-vanillin,  re- 
agent is  prepared  as  follows: 


Gm.  or  Cc. 


1$ — Phloroglucini .      .  2 

Vanillini 1 

Alcoholis  absoluti 30 

Misce. 


0  3ss 

0  gr.  xv 

0  5j 


Three  drops  of  filtered  stomach  contents  are  placed  in  a  porcelain 
spoon  or  dish  (Fig.  4,  g)  ;  to  this  3  drops  of  the  reagent  are  added 
from  a  small  pipet,  and  the  two  solutions  are  thoroughly  mixed. 
The  porcelain  spoon  or  dish  is  then  very  carefully  heated  over  a 
small  flame  (Fig.  4,  i),  when  if  free  hydrochloric  acid  is  present  a 
cherry  red  tint  is  obtained  around  the  edges  of  the  mixture  (Plate 
I,  Figs.  3  and  4).  This  color  is  due  to  the  deposition  of  very  fine 
crystals,  an  effect  which  would  occur  in  even  aqueous  solutions  of 
0.01  per  cent,  of  the  reagent.  This  peculiar  color  is  not  developed 
by  any  organic  acid  whatsoever. 

Instead  of  the  phloroglucin  solution,  a  filter  paper  prepared  by 
means  of  it  is  sometimes  used;  when  moistened  with  two  or  three 
drops  of  stomach  contents  and  heated,  it  reveals  the  presence  of 
hydrochloric  acid  by  developing  the  same  cherry-red  tint.  The  test 
with  the  solution  is  more  reliable. 


QUANTITATIVE  ANALYSIS. 

The  buret  is  used  for  all  quantitative  analyses.  It  is  graduated  in 
tenths  of  a  cubic  centimeter,  to  be  easily  read.  The  buret  should  be 
fixed  in  a  perpendicular  position  and  firmly  attached  to  its  stand 
(Fig.  4,  k).  It  should  be  filled  through  a  glass  funnel  with  the 
solution  to  be  used.  Care  must  be  exercised  to  avoid  the  presence 
of  air  bubbles.  The  buret  is  graduated  from  zero  to  30  Cc. 
Allow  enough  of  the  solution  to  run  out  to  remove  the  bubbles  and 


Phenol phthalein  Test. 

Be  fori 


Phenol  phthalein   1 


FIG.   3 


Gunzburg  Test  (Faint   Reaction). 


Gunzburg  Test  (Marked   Reaction). 


QUANTITATIVE  ANALYSIS  77 

to  bring  the  solution  down  to  the  zero  mark.  In  reading  off  the 
quantity  of  solution  that  has  been  used,  great  care  should  be  taken 
to  read  at  the  level  of  the  bottom  of  the  meniscus  formed  by  the 
attraction  of  the  fluid  to  the  cylindric  wall  of  the  buret. 

Normal  Solutions. — For  quantitative  analysis  of  the  aeid  in  the 
gastric  contents,  normal  solutions  are  used.  A  normal  solution  of 
acid  or  alkali  is  one  in  which  each  liter  represents  the  number  of 
grams  of  reagent  resulting  from  dividing  the  molecular  weight  of 
the  substance  by  the  number  of  replaceable  hydrogen  atoms  or 
hydroxyl  groups.  A  decinormal  solution  is  one-tenth  the  strength 
of  the  normal  solution.  It  is  this  latter  that  is  used  in  making 
stomach  analyses.  In  the  various  tests  employed  in  quantitative 
analysis  for  acidity  of  the  gastric  contents,  one-tenth  normal  sodium 
hydrate  is  used  in  the  buret.  The  amount  of  this  alkali  necessary 
to  neutralize  a  given  quantity  of  the  acid  in  the  gastric  juice  will 
give  the  degree  of  acidity.  It  has  been  found  that  the  normal 
acidity  of  the  stomach  contents  at  the  height  of  digestion  (one 
hour  after  a  test  breakfast)  will  range  between  40  and  60  degrees, 
which  means  the  number  of  cubic  centimeters  of  one-tenth  normal 
sodium  hydrate  solution  necessary  to  neutralize  100  cubic  centimeters 
of  gastric  juice.  For  example,  if  we  use  2.5  Cc.  of  one-tenth  normal 
sodium  hydrate  solution  to  neutralize  5  Cc.  of  gastric  juice,  the 
degree  of  acidity  would  be  2.5  X  20  (=  50).  We  multiply  by  20 
because  we  always  figure  on  the  amount  necessary  to  neutralize 
100  Cc.  of  gastric  juice,  and  since  we  have  used  only  5  Cc.  for  the 
test  we  must  multiply  by  20  to  bring  this  up  to  100. 

One  cubic  centimeter  of  one-tenth  normal  sodium  hydrate  solution 
will  neutralize  0.00365  gram  of  free  hydrochloric  acid.  If  now  we 
multiply  this  factor  by  the  number  of  cubic  centimeters  necessary 
to  neutralize  100  Cc.  of  the  filtered  gastric  juice  (degree  of  acidity), 
the  result  will  be  the  percentage  of  acid  present.  If  the  normal 
acidity  is  between  40  and  60  degrees,  the  percentage  will  be  found 
by  multiplying  by  0.00365. 

Minimum  normal  acidity  40  degrees,  0.00365  X  40  =  0.146  per  cent. 
Maximum  normal  acidity  60  degrees,  0.00365  X  60  =  0.219  per  cent. 

After  the  Ewald-Boas  test  breakfast  an  excess  of  free  hydrochloric 
acid  should  be  present  within  fifty  or  sixty  minutes,  while  after  a 
Riegel  test  dinner  it  is  present  in  from  two  and  a  half  to  three  hours. 

The  elements  to  which  the  acid  reaction  of  stomach  contents  is 
attributable  are  outlined  in  the  following  table: 

1.  Hydrochloric  acid 

free  combined 

(with  proteins,  basic  substances) 

2.  Organic  acids  (lactic,  butyric,  acetic  acids) 


free  combined 

(with  proteins,  basic  substances) 
3.         Acid  phosphates.  * 


78  EXAMINATION  OF  THE  STOMACH  CONTENTS 

Since  the  normal  acidity  of  the  stomach  contents  is  between 
40  and  60  degrees,  clinicians  have  for  the  most  part  agreed  that 
above  60  degrees  shall  constitute  hyperchlorhydria,  hyperacidity, 
or  superacidity;  below  40  degrees,  hypochlorhydria,  hypoacidity, 
or  subacidity;  absence  of  acid,  achlorhydria,  anacidity,  or  achylia. 
The  total  acidity  is  ascertained  by  the  phenolphthalein  test  (see 
page  79). 

The  unfiltered  gastric  contents  reveal,  on  analysis,  a  higher 
acidity  than  the  filtered,  and  it  has  been  suggested  that  such  an 
analysis  would  furnish  a  better  indication  of  the  condition  of  gastric 
secretion  than  analysis  of  the  filtered  contents.  Inasmuch,  however, 
as  the  work  of  Ewald  and  Boas  in  establishing  hydrochloric  acid 
values  was  done  on  filtered  contents,  a  change  would  necessitate  new 
standards,  involving  a  tremendous  amount  of  work. 

Fractional  Analysis. — In  fractional  determination  of  gastric  secre- 
tion, specimens  of  the  gastric  contents  are  withdrawn  at  fifteen- 


Fig.  5. — Rehfuss  gastroduodenal  tube. 

minute  intervals  during  the  cycle  of  digestion,  and  the  free,  com- 
bined and  total  acids  are  titrated.  For  withdrawing  the  stomach 
contents  for  examination,  either  the  duodenal  tube  described  on 
page  98  or  a  Rehfuss  stomach  tube  may  be  used.  The  Rehfuss 
instrument  is  an  ordinary  rubber  tube  with  a  metal  end  having 
slit-like  openings,  each  equal  in  width  to  the  inner  diameter  of  the 
tube  (Fig.  5) .  Aspiration  is  greatly  facilitated  by  the  size  of  these 
openings.  The  patient  takes  an  ordinary  Ewald-Boas  test  break- 
fast, and  ten  minutes  later  the  tube  is  swallowed  with  two  ounces  of 
water.  The  patient  is  placed  at  ease,  either  sitting  or  lying  down, 
and  urged  to  read  to  divert  his  attention.  At  intervals  of  fifteen 
minutes  15  to  20  Cc.  of  the  stomach  contents  is  withdrawn  until 
the  stomach  is  empty.  By  testing  each  portion,  the  whole  cycle 
of  digestion  is  recorded  (Fig.  6). 

The  motor  power  of  the  stomach  is  demonstrated  by  the  disap- 
pearance of  all  food  particles  from  the  fifteen-minute  samples. 


QUANTITATIVE  ANALYSIS 


79 


By  this  method  of  examination  it  is  possible  to  follow  the  entire 
cycle  of  gastric  digestion  with  practically  no  discomfort  to  the 
patient,  and  to  draw  off  at  any  moment  a  sufficient  quantity  of  the 
gastric  juice  for  the  necessary  chemical  examinations.  The  principle 
of  the  entrance  and  retention  of  the  Rehf uss  tube  is  gravity ;  the  tip 
is  sufficiently  heavy  to  seek  the  lowest  portion  of  the  stomach.  The 
instrument  is  left  in  the  stomach  for  hours,  or  until  the  gastric  cycle 
is  completed.  A  curve  can  be  constructed  which  graphically  records 
the  entire  course  of  digestion.  Information  as  to  the  amount  of  the 
secretion  can  be  obtained  at  any  point  in  the  progress  of  digestion, 
by  complete  aspiration  and  noting  the  character  of  the  specimens 
obtained.  There  is  no  specific  curve  for  the  normal  person;  but 
three  types  of  curve  can  be  found,  illustrating  the  rapidity  of  reac- 
tion to  a  given  stimulus,  the  height  of  the  curve,  and  its  descent. 
These  types  have  been  termed,  respectively,  the  hypersecretory, 
the  hyposecretory,  and  the  isosecretory. 


70 
60 

50 

40 

30 

20 

10 

MINUTES   0 


15 


30 


45 


60 


75 


90 


105        120 


135 


150       165 


Fig.  6. — A  fractional  test  breakfast  secretory  curve,  showing  the  degree  of  acidity 

in  a  normal  case. 


The  value  of  the  interval  method  of  gastric  analysis  is  obvious. 
^Yhile  the  ordinary  method  of  examining  the  stomach  contents 
one  hour  after  the  test  meal  is  taken  gives  evidence  of  only  a 
single  moment  in  an  ever-changing  cycle  of  gastric  activity,  the 
fractional  determination  shows  (a)  stomach  secretions  whose  curves 
fall  toward  the  end  of  gastric  digestion;  (6)  stomach  secretions  whose 
curves  rise  at  the  end  of  gastric  digestion;  (c)  stomach  secretions 
absent  or  delayed.  By  fractional  analysis  of  the  stomach  secre- 
tions a  diagnosis  of  hyperchlorhydria,  hypochlorhydria  or  achylia  is 
more  firmly  established  than  by  the  one-hour  stomach  examination 
which  gives  no  evidence  of  the  secretory  curve. 

Phenolphthalein  Test  for  Total  Acidity. — The  total  acidity  is  deter- 
mined with  one-tenth  normal  sodium  hydrate  solution  in  the  buret. 
The  indicator  consists  of  a  1-per-cent.  alcoholic  solution  of  phenol- 
phthalein. Draw  into  a  graduated  pipet  10  Cc.  of  the  filtered 
gastric  juice  (Fig.  4,  f).     Pour  the  contents  of  the  pipet  into  a 


80  EXAMINATION  OF  THE  STOMACH  CONTENTS 

beaker  (Fig.  4,  h).  To  this,  add  three  or  four  drops  of  the  phenol- 
phthalein  solution,  which  will  cause  a  grayish  clouding  (Plate  I, 
Fig.  1).  The  one-tenth  normal  sodium  hydrate  solution  is  gradually 
added  until  red  is  discerned  at  the  point  where  the  solution  from  the 
buret  touches  the  gastric  juice.  By  agitation,  the  red  color  dis- 
appears. Add  more  of  the  sodium  hydrate  solution  and  again  agi- 
tate the  contents  of  the  beaker.  ^Yhen  the  reddish  color  ceases  to 
disappear,  a  sufficient  quantity  of  the  one-tenth  normal  sodium 
hydrate  solution  has  been  added  to  neutralize  the  total  acidity  of  the 
stomach  contents.  Care  must  be  taken  not  to  add  too  much.  The 
end  of  the  test  shows  a  slight  red  (Plate  I,  Fig.  2).  It  is  now  neces- 
sary to  read  on  the  buret  the  amount  used.  If  we  have  used  4.5 
Cc.j  we  multiply  by  10,  because  we  calculate  the  amount  necessary 
to  neutralize  100  Cc,  whereas  we  have  used  only  10,  and  we  find 
that  our  acidity  is  45  degrees.  The  percentage  of  acidity  is  ascer- 
tained by  multiplying  the  45  by  0.00365,  making  0.16425  per  cent. 

It  is  very  important  to  make  a  quantitative  estimate  of  free  hydro- 
chloric acid  in  studying  all  pathologic  conditions  of  the  stomach. 
When,  however,  the  amount  of  free  hydrochloric  acid  is  dimin- 
ished, it  is  necessary  to  exercise  caution  in  the  interpretation  of 
either  qualitative  or  quantitative  tests  for  free  hydrochloric  acid. 
In  comparatively  rare  cases  all  the  indicators,  with  the  exception 
of  Giinzburg's  reagent,  have  given  a  positive  reaction  for  hydro- 
chloric acid  when  no  hydrochloric  acid  was  actually  present. 

Tbpfer's  Method  of  Quantitative  Analysis. — This  is  the  simplest 
and  most  delicate  of  tests  for  free  hydrochloric  acid.  One-half 
per  cent,  dimethylamidoazobenzol  alcoholic  solution  is  used  as  an 
indicator.  The  titration  of  the  filtered  gastric  juice  is  done  with 
decinormal  sodium  hydrate  solution.  Lactic  acid  will  not  react  to 
the  test  unless  it  is  present  to  the  extent  of  1  per  cent.,  which  is 
rarely  the  case.  Acetic  and  butyric  acids  are  present  in  fairly 
large  amounts  in  fermentative  processes  of  the  stomach;  when 
present  in  sufficient  quantities  to  interfere  with  the  reaction  for 
hydrochloric  acid,  their  strong  odor  renders  them  easy  of  detec- 
tion. To  10  Cc.  of  the  filtered  gastric  juice,  one  or  two  drops  of 
indicator  are  added;  if  hydrochloric  acid  is  present,  a  bright  red 
tone  results  (Plate  II,  Fig.  1),  so  the  mere  presence  or  absence  of 
hydrochloric  acid  is  easily  determined.  The  quantitative  deter- 
mination is  now  made  by  adding  decinormal  sodium  hydrate  solu- 
tion; as  this  solution  is  added,  the  reddish  tint  of  the  mixture 
changes  to  a  distinct  yellow.  The  titration  must  proceed  to  the 
point  at  which  all  trace  of  red  disappears  and  the  color  becomes 
clear  yellow  (Plate  II,  Fig.  2).  To  ascertain  the  amount  of  free 
hydrochloric  acid  present,  note  the  number  of  cubic  centimeters  of 
decinormal  sodium  hydrate  solution  used  from  the  buret.  Multiply 
this  by  10,  in  order  to  determine  the  amount  necessary  to  neu- 
tralize 100  Cc.  of  gastric  juice — the  figures  also  representing  the 


PLATE    II 


Topfer  Test. 


Dimethylamidoazobenzol    as    in- 
or,  before  adding  j*.  sodium 
rate  solution. 


Topfer  Test 

Dimethylamidoazobenzol  as  in- 
dicator, after  rendering  alkaline 
with    **    sodium  hydrate  solution. 


FIG.   3 


FIG.   4 


Topfer  Test. 

Alizarin  as  indicator,  before 
adding  2s  sodium  hydrate 
solution. 


Topfer  Test. 

Alizarin  as  indicator,  after  ren- 
dering alkaline  with  *  sodium 
hydrate  solution. 


QUANTITATIVE  ANALYSIS  81 

degree  of  free  hydrochloric  acid  present.    Multiplying  this  result 
by  0.00365  we  get  the  percentage  of  hydrochloric  acid. 

In  making  these  tests  the  physician  should  always  work  with 
filtered  gastric  contents,  since  otherwise,  owing  to  the  presence  of 
food  particles,  an  exact  measurement  of  the  quantity  of  gastric 
juice  can  seldom  be  made. 

Combined  Hydrochloric  Acid. — Since  the  hydrochloric  acid  at 
first  secreted  combines  with  basic  substances  and  the  protein  of 
the  ingested  food,  if  we  would  know  the  total  amount  of  hydrochloric 
acid  secreted  we  must  ascertain  just  how  much  acid  salts  and  acid 
protein  has  been  formed  in  the  stomach.  The  physiologically 
active  hydrochloric  acid  consists  of  both  free  and  combined  acid. 
There  may  be  only  a  small  amount  of  free  hydrochloric  acid  while 
that  combined  with  the  protein  may  be  comparatively  large.  Some- 
times there  is  no  free  hydrochloric  acid,  but  a  large  quantity  of 
combined  acid,  showing  that  a  certain  amount  has  been  secreted 
by  the  stomach. 

The  total  acidity  of  the  gastric  juice  is  determined  by  titration 
of  10  Cc.  of  filtered  gastric  juice  with  decinormal  sodium  hydrate 
solution,  using  phenolphthalein  as  an  indicator,  as  described  on 
page  79.  This  point  having  been  determined,  a  second  portion 
of  10  Cc.  of  gastric  juice  is  titrated  with  decinormal  sodium  hydrate 
solution,  using  a  1-per-cent.  aqueous  solution  of  alizarin  as  an 
indicator  (alizarin  monosulphate  of  sodium).  Two  or  three  drops 
of  this  indicator  are  added  to  10  Cc.  of  filtered  gastric  juice,  and 
the  mixture  becomes  distinctly  yellow  (Plate  II,  Fig.  3).  The 
titration  is  carried  to  the  point  of  production  of  a  pure  violet  color 
(Plate  II,  Fig.  4)  which  does  not  deepen  on  the  further  addition 
of  an  alkali.  Alizarin  reacts  with  free  acid,  both  mineral  and 
organic,  and  with  free  acid  salts,  but  not  with  combined  hydro- 
chloric acid.  If,  therefore,  we  substract  the  figure  obtained  when 
alizarin  is  used  as  an  indicator  from  that  obtained  with  phenol- 
phthalein, the  result  will  be  combined  hydrochloric  acid.  For 
example:  Suppose  that  by  the  use  of  phneolphthalein  and  deci- 
normal sodium  hydrate  solution  all  the  acidities  have  been  saturated, 
the  color  being  red,  and  the  result  is  60  degrees;  then  by  the  use 
of  alizarin  and  decinormal  sodium  hydrate  solution  all  the  acidity 
excepting  the  combined  hydrochloric  acid  is  neutralized,  the  color 
being  violet,  and  the  result  is  38  degrees.  By  subtracting  the  acidity 
found  with  alizarin  (38)  from  the  acidity  found  with  phenolphthalein 
(60)  the  amount  of  combined  hydrochloric  acid  is  determined: 
60  -  38  =  22,  and  22  X  0.00365  =  0.0803  per  cent.  If  we  now 
add  this  hydrochloric  acid  to  the  free  hydrochloric  acid  determined 
by  titration  of  the  gastric  juice,  using  dimethylamidoazobenzol 
as  an  indicator,  we  obtain  the  total  physiologically  active  hydro- 
chloric acid.  The  difference  between  the  total  acidity  and  this 
factor  gives  us  the  amount  of  organic  acid  and  acid  salts  present. 
6 


82 


EXAMINATION  OF  THE  STOMACH  CONTENTS 


25c.c 


Lactic  Acid. — Since  bread,  milk  and  meat  contain  lactic  acid,  any 
test  for  lactic  acid  can  be  of  value  only  when  the  meal  contains  very 
little  of  these  foods.  The  Boas  test  meal  (page  67)  is  preferable 
when  the  object  is  to  detect  the  presence  of  lactic  acid.  Under 
physiologic  conditions  no  appreciable  amount  of  lactic  acid  is  formed 
during  digestion.    Lactic  acid  is  apt  to  be  found  in  any  condition 

associated  with  stagnation  of  the  gastric 
contents  as  a  result  of  motor  insuffi- 
ciency, provided  the  amount  of  hydro- 
chloric acid  is  below  normal.  An  excess 
of  lactic  acid  would  suggest  gastric 
carcinoma,  though  it  should  not  be 
overlooked  that  an  excess  of  lactic  acid 
may  be  present  in  benign  stenosis  of 
the  pylorus  and  motor  insufficiency. 
Should  the  stomach  be  washed  out 
the  evening  before,  and  lactic  acid 
appear  in  the  stomach  contents  after 
the  night's  fast,  the  pathologic  condi- 
tion is  probably  carcinoma.  Where 
carcinoma  has  developed  from  the 
overhanging  edge  of  a  callous  ulcer, 
the  findings  may  show  no  lactic  acid, 
but,  on  the  contrary,  large  amounts 
of  hydrochloric  acid. 

Uffelmann's  Test. — Uffelmann's  re- 
agent consists  of  10  Cc.  of  a  4-per- 
cent, carbolic  acid  solution  to  which 
are  added  one  drop  of  ferric  chlorid 
solution  U.  S.  P.  and  sufficient  water 
to  produce  a  transparent  amethyst  blue 
(Plate  III,  Fig.  1) .  The  solution  should 
be  freshly  prepared  for  each  test.  Add 
a  few  drops  of  the  filtrate  from  the 
stomach  contents  after  a  Boas  test  meal 
(p.  67)  to  5  Cc.  of  the  Uffelmann  re- 
agent in  a  test  tube,  and  in  the  pres- 
ence of  lactic  acid  the  solution  will 
lose  its  blue  color  and  take  on  a 
beautiful  canary  yellow  or  greenish- 
yellow  tint  (Plate  III,  Fig.  2).  Should  there  be  considerable  hydro- 
chloric acid  present  in  the  gastric  juice  the  result  may  be  obscured. 
The  stomach  contents  under  this  condition  should  be  extracted 
with  ether,  which  takes  up  the  lactic  acid  only.  The  ethereal  solu- 
tion is  then  evaporated,  the  residue  taken  up  with  distilled  water, 
and  the  Uffelmann  test  applied  to  this  solution;  if  lactic  acid  is 
present,  the  solution  turns  intensely  green. 


5c.c 


Fig.  7. — Strauss'  funnel  for  mak 
ing  lactic  acid  test. 


PLATE    III 


Uffelmann's  Test. 

Fig.   1.     Before  adding  gastric  filtrate  containing  lactic  acid. 
Fig.  2.      After  adding  gastric  filtrate  containing  ieid. 


EXAMINATION  FOR  ENZYMES  83 

Strait.™  Test.  Strauss  has  devised  a  glass  funnel  (Fig.  7)  which 
makes  the  test  for  lactic  acid  quite  simple.  The  funnel  is  gradu- 
ated to  5  Cc.  below  and  25  Cc.  above.  It  is  filled  to  the  5-Cc.  mark 
with  filtered  gastric  juice,  and  ether  is  added  up  to  the  25-Cc. 
mark.  The  funnel  is  corked  and  thoroughly  shaken.  After 
standing  for  a  short  time  to  allow  the  fluids  to  separate,  the  contents 
are  allowed  to  run  out  through  the  stopcock  to  the  5-Cc.  mark.  1  )is- 
tilled  water  is  added  up  to  the  25-Cc.  mark,  and  then  two  drops  of 
tincture  of  iron  chlorid.  On  shaking  the  mixture,  if  an  appreciable 
quantity  of  lactic  acid  is  present  an  intense  green  color  results;  a 
pale  green  indicates  a  trace  of  lactic  acid. 

EXAMINATION  FOR  ENZYMES. 

Pepsinogen  and  Pepsin. — Through  the  action  of  acids,  and  espe- 
cially hydrochloric  acid,  pepsinogen  is  converted  into  active 
pepsin.  If  the  gastric  contents  contain  free  acids  and  digested 
proteins,  pepsin  is  present.  If  there  are  no  free  acids,  but  the  diges- 
tive power  becomes  apparent  when  the  material  is  treated  with 
sufficient  hydrochloric  acid,  pepsin  is  demonstrated.  To  ascertain 
the  presence  of  pepsin  when  free  hydrochloric  acid  is  present,  10 
Cc.  of  gastric  contents  is  placed  in  a  test  tube,  a  little  disk  of 
coagulated  egg  protein  added,  and  the  test  tube  placed  in  an  incu- 
bator, which  is  kept  at  a  constant  temperature  between  98°  and 
100°  F.;  disappearance  of  the  egg  protein  after  a  short  interval 
points  to  the  presence  of  pepsin. 

"When  hydrochloric  acid  is  absent,  pepsinogen  alone  may  be 
found  in  the  stomach  contents.  This  is  important  to  the  diagnos- 
tician, inasmuch  as  pepsinogen  is  rarely  absent.  The  absence  of 
pepsinogen  means  atrophy  or  achylia.  In  the  absence  of  hydro- 
chloric acid,  pepsinogen  is  practically  inert.  The  test  for  pepsinogen 
is  made  by  adding  to  10  Cc.  of  filtered  gastric  juice  one  or  two 
drops  of  hydrochloric  acid  and  proceeding  as  with  the  qualitative 
test  for  pepsin. 

Determination  of  Pepsin. — Ricin  Test  (Jacoby-Sohns  Method). — 
One  gram  of  ricin  is  dissolved  in  100  Cc.  of  a  5-per-cent.  solution 
of  sodium  chlorid,  and  the  whole  filtered.  Two  cubic  centimeters 
of  the  filtrate  are  mixed  with  0.5  Cc.  of  a  decinormal  HC1  solution, 
1  Cc.  of  diluted  stomach  contents  is  added,  and  the  mixture  is 
maintained  at  body  temperature  for  three  hours.  Ferments 
clear  up  the  ricin  deposit.  The  quantity  of  pepsin  is  determined 
from  the  degree  of  dilution  in  which  the  stomach  contents  will 
cause  the  ricin  deposit  to  disappear.  Solms  considers  one  pepsin 
unit  the  amount  of  gastric  juice  which  is  sufficient  to  clear  up  2  Cc. 
of  a  2-per-cent.  ricin  solution  in  three  hours  at  blood  temperature. 
Normal  stomach  contents  contain  about  100  pepsin  units  to  the  cubic 
centimeter. 


84  EXAMINATION  OF  THE  STOMACH  CONTEXTS 

Mett's  Test. — A  capillary  glass  tube  is  used,  into  which  fresh  .egg 
protein  is  drawn  by  suction.  The  contents  of  the  tube  are  coagu- 
lated by  immersion  for  five  minutes  in  boiling  water.  By  cutting 
the  tube  into  pieces  2  to  5  centimeters  long  the  pieces  can  easily 
be  placed  in  a  beaker  containing  the  gastric  juice  to  be  tested. 
They  should  then  be  kept  in  an  incubator  for  ten  hours  at  a  tem- 
perature of  95°  to  98°  F.  At  the  end  of  this  time  the  protein  will 
be  seen  to  have  disappeared  from  the  ends  of  each  piece,  while 
there  still  remains  some  in  the  middle  portion  of  each.  The  empty 
ends  are  measured.  The  square  of  the  length  of  the  column  of 
protein  digested  is  the  measure  of  the  amount  of  pepsin  in  the  gastric 
juice.  For  instance,  if  the  empty  portion  of  the  tube  be  3  milli- 
meters in  length  the  digestion  equals  3  X  3,  or  9  parts  of  pepsin. 
The  peptic  unit  is  that  quantity  of  pepsin  which  will  digest  one 
millimeter  of  egg  protein  in  a  Mett  tube  in  ten  hours,  the  tubes 
being  immersed  in  0.18-per-cent.  free  hydrochloric  acid. 

The  Gelatin  Test. — Ramond,  Petit  and  Carrie  describe  a  simple 
procedure  shoving  both  the  peptic  power  and  the  hydrochloric 
acidity  of  given  samples  of  gastric  juice.  Five  Cc.  of  3-per-cent. 
gelatin  solution  is  placed  in  a  test  tube  15  millimeters  in  diam- 
eter; the  tube  is  then  sterilized  at  100°  C,  and  kept  exactly  vertical 
during  solidification  of  the  gelatin.  Five  Cc.  of  filtered  gastric  juice 
is  then  placed  over  the  gelatin,  and  0.02  Gm.  of  thymol  added. 
xALlowed  to  stand  at  room  temperature,  a  few  hours  later  the  tube 
shows  a  definite  ring  in  the  gelatin,  the  time  of  its  appearance 
depending  upon  the  acidity  of  the  specimen  of  gastric  juice.  In 
anacidity  or  marked  hypoacidity  no  ring  forms.  To  ascertain  the 
rapidity  of  digestion,  a  paper  index  may  be  pasted  along  the  tube 
or  the  latter  may  be  graduated  in  millimeters.  Xormal  gastric 
juice  digests,  on  an  average,  two  and  one-half  millimeters  of  gelatin 
in  twenty-four  hours.  The  digestion  continues  regularly  until  all  the 
gelatin  has  been  consumed.  Several  tubes  should  be  used  for  each 
specimen,  and  an  average  taken.  The  acid  ring  in  the  gelatin  is 
most  clearly  seen  when  the  tube  is  held  against  the  fight. 

Qualitative  Test  for  Rennin.- — Five  to  ten  cubic  centimeters  of  fil- 
tered stomach  contents  are  accurately  neutralized  with  decinormal 
sodium  hydrate  solution.  The  same  quantity  of  neutral  or  ampho- 
teric boiled  milk  is  added  and  the  mixture  placed  in  an  incubator. 
If  the  curdling  process  begins  within  fifteen  minutes  and  a  eoagu- 
lum  is  formed  when  the  mixture  is  allowed  to  stand  longer,  the 
phenomenon  of  coagulation  is  attributable  to  the  action  of  rennin. 

To  test  for  rennin  zymogen,  add  three  to  five  drops  of  a  1  -per-cent. 
calcium  chlorid  solution  to  10  Cc.  of  milk  to  which  three  to  four  drops 
of  gastric  filtrate  have  been  added,  and  place  in  an  incubator.  If 
coagulation  of  casein  occurs  in  the  course  of  a  few  minutes,  rennin 
zymogen  is  present. 

A  pronounced  diminution  of  the  specific  biologic  action  of  fer- 


CARBOHYDRATE  DIGESTION  1\    THE  STOMACH 

imnts  is  directly  indicative  of  disturbance  of  the  function  of  the 
glandular  apparatus  of  the  stomach  itself.  By  examination  of  the 
gastric  enzymes  it  may  be  determined  in  individual  eases  whether 
impairment  of  the  glandular  apparatus  is  transitory  or  permanent. 

Hydrochloric  acid  secretion  is  sometimes  temporarily  inhibited  in 
anomalies  of  menstruation,  in  appendicitis,  in  nervous  dyspepsia,  in 
cholelithiasis,  and  in  acute  and  the  early  stages  of  chronic  gastritis. 
In  these  conditions  the  presence  or  absence  of  enzymes  indicates 
whether  the  physician  has  to  deal  with  only  a  temporary  suppression 
of  the  hydrochloric  acid  secretion  or  with  an  advanced  or  chronic 
gastric  catarrh. 

Test  for  Propeptone. — The  end-products  of  protein  digestion  in 
the  stomach  are  propeptones  and  peptones.  The  aminoacids  are 
all  formed  in  the  intestine.  To  test  for  propeptone,  mix  equal  parts 
of  the  filtered  stomach  contents  and  a  saturated  solution  of  sodium 
chlocid.  A  turbid  precipitation  indicates  the  presence  of  propep- 
tones. When  there  is  no  precipitation,  but  the  addition  of  two 
or  three  drops  of  acetic  acid  turns  the  liquid  turbid,  propeptone  is 
present.  When  the  solution  is  heated  the  turbidity  clears  up,  and 
when  it  cools  the  turbidity  returns.  The  more  turbid  the  solution, 
other  things  being  equal,  the  greater  the  amount  of  propeptone 
present. 

Test  for  Peptone. — After  having  filtered  out  the  propeptone, 
5  Cc.  of  the  filtrate  is  made  strongly  alkaline  by  adding  sodium 
hydrate  solution.  A  few  drops  of  a  1-per-cent.  sulphate  of  copper 
solution  are  added.  When  peptone  is  present,  a  purple  or  violet-red 
color  (biuret  reaction)  appears. 

CARBOHYDRATE  DIGESTION  IN  THE  STOMACH. 

The  conversion  of  starches  into  sugar  occupies  three  intermediary 
stages,  which  are  determined  by  their  behavior  toward  Lugol's 
solution.  The  stages  are  amidulin,  erythrodextrin,  and  achroodex- 
trin  (see  page  50).  With  Lugol's  solution,  amidulin  gives  a  blue 
color,  erythrodextrin  a  violet  or  mahogany  brown,  achroodextrin 
remains  unchanged.  The  end-product  of  the  conversion  of  starch 
into  sugar  is  maltose,  together  with  small  amounts  of  dextrose, 
which  may  be  demonstrated  by  Fehlmg's  or  Xylander's  tests. 
Lugol's  solution  consists  of  pure  iodin,  1  gram;  potassium  iodid,  2 
grams;  distilled  water,  enough  to  make  20  Cc. 

In  h}-perchlorhydria  the  digestion  of  starch  has  been  found  to 
be  considerably  impaired;  in  testing  the  stomach  contents  for  starch, 
iodin  gives  a  pronounced  blue  coloring.  In  achlorhydria  the  reac- 
tion is  wine-yellow.  The  first  result  is  more  likely  to  be  obtained 
when  there  is  an  impairment  of  the  salivary  glands  whereby  the 
secretion  becomes  poor  in  ptyalin.  In  any  case  where  hyperacidity 
is  present,  salivary  digestion  stops  as  soon  as  the  food  enters  the 


86  EXAMINATION  OF  THE  STOMACH  CONTENTS 

stomach;  in  subacid  conditions  salivary  digestion  may  proceed 
indefinitely  in  the  stomach,  depending,  of  course,  upon  the  extent 
of  the  diminution  of  gastric  secretion. 

BLOOD  IN  THE  STOMACH  CONTENTS. 

The  presence  of  blood  in  the  stomach  contents  must  be  considered 
always  pathologic;  it  is  most  frequently  associated  with  erosion, 
gastric  ulcer,  or  gastric  carcinoma.  It  may  be  due  to  the  rupture 
of  varices  in  the  lower  part  of  the  esophagus  caused  by  cirrhosis  of 
the  liver.  In  gastric  ulcer  the  blood  is  usually  bright  red  in  appear- 
ance, unless  changed  by  the  action  of  the  acid  of  the  gastric  juice, 
in  which  case  it  takes  on  a  brownish  discoloration.  In  hemor- 
rhages resulting  from  gastric  carcinoma  the  blood  is  more  thoroughly 
incorporated  with  the  stomach  contents,  giving  rise  to  the  so-called 
coffee-ground  material,  of  brownish-black  appearance. 

Weber's  Guaiac  Test.— A  small  quantity  of  the  gastric  filtrate 
is  rubbed  up  with  water;  one-third  its  volume  of  glacial  acetic 
acid  is  then  added  and  the  mixture  shaken  up  with  ether  in  a 
test  tube.  The  acetic  acid  decomposes  hemoglobin  and  liberates 
hematin,  which  is  in  turn  taken  up  by  the  ether.  The  clear  super- 
natant ether  is  then  poured  off,  ten  drops  of  an  alcoholic  solution 
of  resin  of  guaiac  are  mixed  with  it,  and  lastly,  twenty  to  thirty 
drops  of  turpentine  or  Huehnef eld's  reagent  are  added.  A  blue 
color  appearing  at  once  points  to  the  presence  of  blood  in  considerable 
quantity.  Delayed  appearance  of  the  blue  color  is  an  indication 
of  smaller  quantities  of  blood. 

TESTS  FOR  CARCINOMA. 

Salomon's  Test. — The  principle  underlying  this  test  is  the  fact 
that  carcinoma  secretes  protein,  which  becomes  mixed  with  the 
gastric  contents.  The  diet  of  the  patient  for  twenty-four  hours 
prior  to  the  test  should  be  absolutely  free  from  protein.  At  the 
beginning  of  this  period  he  is  given  a  morning  meal  of  milk  and 
gruel  and  a  mid-day  meal  of  bouillon  with  coffee  or  tea.  Late 
in  the  evening  the  stomach  should  be  washed  out  with  large  quan- 
tities of  pure  water  until  the  return  water  is  clear.  The  follow- 
ing morning  the  fasting  stomach  is  washed  twice  with  400  Cc. 
of  physiologic  salt  solution,  the  same  solution  being  used  each 
time.  This  solution  is  then  tested  by  the  Kjeldahl  method  for  the 
total  amount  of  nitrogen,  and  by  Esbach's  method  for  the  quanti- 
tative estimation  of  protein.  Salomon  found  in  cases  of  gastric 
carcinoma  20  to  70  milligrams  of  nitrogen  and  from  0.00625  to 
0.05  per  cent,  of  protein  to  each  100  Cc.  of  the  fluid  that  had 
been  used  in  lavage.  In  non-malignant  cases,  according  to  this 
investigator,  no  protein  could  be  detected,  and  the  amount  of  nitro- 
gen varied  from  none  to  16  milligrams  in  each  100  Cc. 


TESTS  FOR  CARCINOMA  87 

Wolff  and  Junghans  Test-  This  test  depends  upon  estimation 
of  the  amount  of  soluble  protein  present  in  the  gastric  contents, 
and  is  one  of  the  most  reliable  in  use.  The  assumption  is  that  a 
gastric  carcinoma  secretes  a  peptid-splitting  ferment  that  converts 
insoluble  protein  into  soluble  protein.  The  test  is  useless  when 
hydrochloric  acid  is  present  in  the  stomach,  and  is  therefore  of  value 
only  in  cases  of  aclilorhydria.  Wolff  and  Junghans  found  large 
quantities  of  soluble  protein  in  the  gastric  contents  in  cases  of  car- 
cinoma, while  in  benign  cases  of  aclilorhydria  only  minute  quantities 
are  found.  The  soluble  protein  is  demonstrated  by  precipitation 
with  the  following  reagent: 

Gm.  or  Cc. 

1^ — Acidi  phosphotungstici 0  3  Tl\v 

Acidi  hydrochlorici 10  TTlxv 

Alcoholis 20  0  3v 

Aquae  destillatae     .      .      .      .      q.  s.  ad    200  0  5vij 

Misce. 

This  reagent  should  be  kept  in  a  cool  place. 

Six  test  tubes,  holding  varying  quantities  of  filtered  gastric  juice, 
from  0.0025  Cc.  to  1  Cc,  are  diluted  up  to  10  Cc.  with  distilled 
water.  With  a  pipet  1  Cc.  of  the  reagent  is  carefully  placed  upon 
the  contents  of  each  test  tube.  At  the  junction  of  the  reagent  and 
the  diluted  gastric  juice  a  definite  white  ring  must  appear  in  all 
six  tubes  for  the  test  to  be  positive,  for  in  normal  cases  it  will 
appear  in  dilutions  containing  as  much  as  1  part  of  gastric  juice  to 
40  of  water. 

Cytodiagnosis. — Loeper  and  Binet  devised  the  cytodiagnosis  of 
carcinoma  of  the  stomach.  The  method  consists  in  washing  out  the 
stomach  by  introducing  \  liter  {\  pint)  of  normal  saline  solution  and 
removing  it,  centrifugalizing,  and  exainining  for  carcinomatous  cells. 
The  solution  should  reach  all  portions  of  the  gastric  mucosa.  With 
the  solution  in  the  stomach,  the  patient  should  lie  down  and  sit 
up  several  times  and  the  organ  be  carefully  kneaded.  Enough 
freshly  loosened  carcinomatous  cells  can  thus  be  obtained  to  yield 
a  positive  diagnosis. 

Glycyltryptophan  Test. — Xeubauer  and  Fischer  state  that  car- 
cinoma of  the  stomach  secretes  a  ferment  which,  unlike  pepsin,  splits 
glycyltryptophan,  and  that  this  ferment  can  be  detected  in  the 
stomach  contents  in  the  early  stages  of  gastric  carcinoma.  On  the 
other  hand,  it  has  been  shown  by  Warfield  that  saliva,  when  mixed 
with  neutral  or  faintly  acid  gastric  juice,  imparts  to  the  latter  the 
power  of  separating  tryptophan  from  glycyltryptophan.  Jacque 
and  Woodyatt  affirm  as  a  result  of  their  later  investigations  that 
saliva  free  from  bacteria  does  not  split  glycyltryptophan;  also  that 
normal  gastric  juice  free  from  blood,  bile,  and  bacteria,  and  gastric 
juice  from  cases  of  benign  subacidity,  have  no  peptid-splitting  action. 
In  the  glycyltryptophan  test  the  presence  of  tryptophan  is  mani- 
fested by  the  development  of  a  rose-red  color  in  the  gastric  contents 


88  EXAMINATION  OF  THE  STOMACH  CONTENTS 

under  test  on  the  gradual  addition  of  bromin  vapor.  A  weak  solu- 
tion of  calcium  hypochlorite  may  be  used  instead  of  bromin  vapor, 
and  gives  the  same  reaction. 

Gluanskfs  Test.— This  test  is  based  upon  the  assumption  that 
gastric  carcinoma  is  always  accompanied  by  a  chronic  gastritis 
which  interferes  with  the  secretion  of  the  gastric  juice.  Examina- 
tion of  the  stomach  contents  after  three  different  test  meals  in  the 
course  of  one  day  reveals  whether  the  gastric  juice  is  being  normally 
secreted.  After  the  first  test  meal  the  percentage  of  hydrochloric 
acid  may  be  normal,  but  if  the  case  is  one  of  gastric  carcinoma  a 
smaller  amount  of  free  hydrochloric  acid  will  be  found  after  the 
second  test  meal,  and  after  the  third  the  percentage  of  hydrochloric 
acid  will  be  found  to  be  greatly  diminished  or  nil.  The  test  is 
remarkably  reliable  in  differentiating  between  carcinoma  and  ulcer, 
since  the  latter  does  not  interfere  with  the  secretion  of  hydrochloric 
acid. 

INDIRECT  METHODS  OF  GASTRIC  ANALYSIS. 

A  number  of  methods  are  in  vogue  for  the  examination  of  the 
functioning  powers  of  the  stomach  without  removing  the  gastric 
contents.  While  such  methods  fail  to  determine  the  exact  condition 
of  the  acidity  or  of  the  activity  of  ferments,  much  may  be  learned 
by  means  of  them  regarding  gastric  motility  as  well  a<  the  digestive 
powers  of  the  stomach. 

Benedict's  Effervescence  Test  for  Acidity.— When  the  stomach  tube 
cannot  be  introduced,  the  effervescence  test  for  gastric  acidity,  first 
described  by  A.  L.  Benedict,  is  of  great  value.  The  test  is  only 
approximate,  and  it  is  not  necessary  to  insist  upon  a  rigid  test  meal. 
It  consists  in  auscultation  of  the  effervescence  produced  when  a 
saturated  solution  of  sodium  bicarbonate  meets  the  gastric  contents. 
One  hour  after  a  test  breakfast  or  three  hours  after  an  ordinary 
meal,  the  patient  standing  before  the  physician  and  cautioned  not 
to  speak,  breathe  heavily,  or  rustle  his  garments,  drinks  30  Cc. 
(1  ounce)  of  the  sodium  solution  at  one  gulp.  In  from  ten  to 
thirty  seconds  a  fine  crepitation  is  heard,  the  stethoscope  being 
placed  over  the  center  of  the  gastric  area.  If  the  gastric  acidity 
is  high,  the  crepitation  is  quite  marked;  if  much  reduced,  prac- 
tically no  crepitation  is  heard. 

Thread  Test  for  Gastric  Acidity. — A  solid  gelatin  capsule  con- 
taining a  heavy  powder  (sulphate  of  sodium)  giving  a  neutral  reac- 
tion can  be  used.  The  capsule  is  pierced  and  a  thread  drawn 
through  it  which  has  been  soaked  for  half  an  hour  in  a  0.25-per-cent. 
aqueous  solution  of  Congo  red.  The  thread  is  120  centimeters  long 
and,  after  passing  through  the  capsule,  is  tied  over  it.  The  capsule 
is  swallowed  half  an  hour  after  a  test  breakfast,  the  free  end  of  the 
thread  being  held  in  the  hand.  After  fifteen  minutes  the  thread 
is  drawn  out,  the  capsule  having  dissolved  in  the  stomach  in  the 


INDIRECT  METHODS  OF  GASTRIC  ANALYSIS  89 

meanwhile.    The  end  of  the  thread  which  has  been  in  the  stomach 

is  now  dark  blue  or  violet  according  to  the  amount  of  hydro- 
chloric acid  in  the  stomach  contents;  if  the  thread  is  still  rv<\,  this 
shows  anacidity  or  that  the  capsule  has  stuck  somewhere  on  its  way. 
By  this  simple  means  the  condition  in  regard  to  acidity  in  the 
stomach  can  be  determined  without  inconveniencing  the  patient. 

Friedrich's  Test. — Another  method  of  testing  for  the  presence 
of  hydrochloric  acid,  without  the  use  of  the  stomach  tube,  is  to 
color  two  tlireads  Congo  red,  one  a  deeper  tint  than  the  other,  tie 
them  snugly  to  a  small  Einliorn  stomach  bucket,  to  which  the  usual 
long  silk  thread  is  attached  for  removal  (see  page  72),  and  have  the 
patient  swallow  bucket  and  colored  threads  half  an  hour  after  a  test 
breakfast,  to  be  withdrawn  a  half-hour  later.  Alteration  of  the 
red  color  to  blue  indicates  the  presence  of  hydrochloric  acid.  Any 
device,  such  as  tying  a  knot  or  a  double  knot  in  one  of  the  threads, 
or  making  one  shorter  than  the  other,  enables  the  observer  to  dis- 
tinguish between  the  two  original  reds.  A  small  metal  button  can 
be  used  instead  of  a  stomach  bucket,  being  placed  within  a  gelatin 
capsule  to  prevent  the  saliva  from  coming  in  contact  with  the  thread. 
Friedrich  has  given  the  name  '*  Gastrognost"  to  this  procedure. 

Another  Simple  Quantitative  Test  of  Acidity. — Take  two  strips  of 
gauze,  four  or  five  centimeters  long  by  one  centimeter  wide.  Dip 
one  strip  in  a  0.5-per-cent.  solution  of  Congo  red  and  the  other  in 
a  0.5-per-cent.  solution  of  dimethylamidoazobenzol.  Fasten  a  long 
thread  (70  cm.)  to  the  two  strips  and  pack  the  strips  into  a  gelatin 
capsule,  pass  the  free  end  of  the  thread  through  the  cap  of  the 
capsule  with  the  aid  of  a  needle,  then  close  the  capsule  with  the  cap 
and  have  the  patient  swallow  it  an  hour  after  a  test  breakfast. 
When  the  capsule  has  dissolved,  the  strips  of  gauze  are  to  be  drawn 
out  by  means  of  the  thread,  and  the  tint  of  the  strips  will  indicate 
the  acidity  of  the  stomach  contents. 

Guuzburg's  Method  of  Testing  the  Absorptive  Power  of  the  Stomach. 
— Two  centigrams  of  potassium  iodid  are  placed  in  a  section  of 
very  thin  though  strongly  vulcanized  rubber  tubing  about  three- 
quarters  of  an  inch  in  length.  The  ends  of  the  tubing*are  folded 
and  tied  with  threads  of  fibrin  hardened  in  alcohol.  To  make  sure 
that  both  ends  are  water-tight,  the  tube  should  be  placed  in  water 
and  allowed  to  remain  for  several  hours,  the  water  being  then  tested 
for  potassium  iodid.  Should  none  of  the  drug  be  found,  the 
patient  is  directed  to  swallow  the  package  three-quarters  of  an 
hour  after  having  partaken  of  an  Ewald  test  meal.  Free  hydro- 
chloric acid  of  the  stomach  will  dissolve  the  fibrin  threads  and 
liberate  the  potassium  salt  into  the  stomach.  The  saliva  should 
be  tested  for  potassium  iodid  at  intervals  of  fifteen  minutes.  When 
the  acid  secretion  is  below  normal  the  salivary  reaction  will  be 
delayed.  In  cases  in  which  the  acid  secretion  is  wholly  absent  the 
potassium  salt  may  not  appear  in  the  saliva  for  at  least  six  hours. 


90  EXAMINATION  OF  THE  STOMACH  CONTENTS 

Sahli's  Desmoid  Test. — By  the  simple  means  of  investigation  of 
the  functions  of  the  stomach  described  by  Sahli  the  physician 
may  avoid  the  annoyance  that  certain  patients  experience  when 
gastric  contents  are  withdrawn  by  means  of  the  stomach  tube  for 
analysis.  The  desmoid  test  is  based  upon  the  observation  of  Adolf 
Schmidt,  that  the  digestion  of  raw  connective  tissue  is  confined 
to  the  stomach.  Raw  connective  tissue  passing  through  the 
stomach  undigested  is  not  affected  by  the  pancreatic  and  intestinal 
juices,  but  is  ejected  with  the  feces  unchanged.  The  details  of  the 
test  are  as  follows:  Two  small  squares  of  rubber  dam,  such  as 
dentists  use,  are  made  into  bags;  into  one  is  placed  1  decigram 
of  iodoform  and  into  the  other  5  centigrams  of  methylene  blue. 
The  bags  are  closed  and  tied  tightly  with  No.  00  raw  catgut  that  has 
been  allowed  to  dry  but  has  not  been  treated  chemically.  The 
patient  is  instructed  to  swallow  the  two  rubber  bags  with  their 
contents.  Under  normal  conditions  of  gastric  secretion  the  catgut 
is  duly  dissolved  and  the  contents  of  the  bags  liberated  into  the 
stomach;  iodin  will  therefore  shortly  appear  in  the  saliva,  and 
methylene  blue  in  the  urine.  Beginning  three  hours  after  the  bags 
are  swallowed,  the  urine  and  the  saliva  should  be  tested  at  one-hour 
intervals.  Should  the  rubber  bags  with  their  contents  pass  through 
the  digestive  canal  unchanged,  gastric  secretion  is  either  very  much 
retarded  or  entirely  absent;  in  such  cases  no  change  is  detected  in 
the  saliva  or  urine.  The  best  time  for  making  the  test  is  imme- 
diately after  the  noon  meal.  Under  normal  conditions  iodin  will 
appear  in  the  saliva  in  about  two  hours  and  methylene  blue  in  the 
urine  within  six  hours.  Any  deviation  from  this  indicates  hyper- 
acidity or  subacidity,  according  to  the  interval  between  the 
administration  of  the  test  agents  and  their  presence  in  the  saliva 
or  urine. 

MOTOR  FUNCTION  OF  THE  STOMACH. 

The  motor  function  of  the  stomach  may  be  determined  by  the 
introduction  of  food  and  subsequent  examination  of  the  stomach 
contents.  For  this  purpose  Leube's  test  meal  is  employed,  which 
consists  of  a  plate  of  soup,  beefsteak,  a  roll,  and  a  glass  of  water; 
or  Riegel's,  consisting  of  300  Cc.  of  beef  broth,  180  grams  of 
beefsteak,  60  grams  of  mashed  potatoes,  and  one  roll.  After  this 
meal  the  patient  must  not  partake  of  anything  during  the  next 
seven  hours.  At  the  end  of  the  seven-hour  period  the  stomach  is 
washed  out,  the  funnel  being  twice  filled  with  about  a  half  liter  of 
water.  If  no  food  remnants  appear,  it  may  be  concluded  that  the 
motor  function  of  the  stomach  is  normal. 

For  practical  purposes  the  motor  function  of  the  stomach  may 
be  determined  by  means  of  a  test  breakfast.  Under  normal  con- 
ditions the  test  breakfast  leaves  the  stomach  in  two  hours  at  most; 
so  if  at  the  end  of  two  hours  large  quantities  of  fluid  or  food  rem- 


PERMEABILITY  OF  THE  PYLORUS 


91 


nants   are  present,   the   motor  function   of  the  stomach    may    be 
regarded  as  impaired. 

Chlorophyl  Test.  —  A  simple  and  rapid  test  for  gastric  motility 
is  the  chlorophyl  test,  of  Boas.  In  the  morning,  on  an  empty 
stomach,  the  patient  drinks  500  Cc.  (1  pint)  of  water  to  which  1 
Cc.  (1G  minims)  of  a  strong  aqueous  solution  of  chlorophyl  has  been 
added.  When  motility  is  normal,  all  but  about  60  Cc.  (2  ounces) 
of  the  water  passes  through  the  pylorus  within  half  an  hour.  The 
liquid  contents  of  the  stomach  can  then  be  re- 
moved with  a  stomach  tube,  and  the  recovered 
chlorophyl,  a  substance  which  is  not  absorbable 
by  the  gastric  mucosa,  enables  us  to  estimate 
the  amount  of  water  remaining  of  the  500  Cc. 
administered.  Not  only  the  fact  but  the  degree 
of  impaired  motility  is  indicated  by  the  liquid  resi- 
due above  GO  Cc.  (2  ounces). 


PERMEABILITY  OF  THE  PYLORUS. 

Einhorn  has  described  a  method  for  testing 
the  permeability  of  the  pylorus.  The  patient  is 
instructed  to  swallow  beads  filled  with  meth- 
ylene blue  and  coated  with  mutton  tallow.  In- 
asmuch as  fat  is  dissolved  in  the  duodenum,  a 
green  or  blue  colored  urine  would  indicate  that 
the  bead  had  passed  the  pylorus  and  that  its 
contents  had  been  absorbed.  Under  normal 
conditions  the  bead  will  pass  into  the  duodenum, 
the  tallow  coating  be  dissolved,  and  the  methyl- 
ene blue  appear  in  the  urine  in  three  to  five  hours. 

The  duodenal  bucket  devised  by  Einhorn  (Fig. 
8)  is  much  smaller  than  the  stomach  bucket.  It 
is  fastened  to  the  end  of  a  braided  silk  thread 
about  80  centimeters  in  length,  and  is  adminis- 
tered to  the  patient  in  a  gelatin  capsule  an  hour 
after  a  small  meal.  The  bucket  should  be  left  in 
the  intestinal  canal  three  hours,  during  which  time 
the  patient  should  not  partake  of  any  food.  The  thread  at  its  free 
extremity  should  be  tied  to  the  ear  so  that  it  cannot  go  beyond  the 
75-centimeter  mark.  After  the  expiration  of  three  hours  the  bucket 
is  slowly  withdrawn.  The  resistance  offered  at  the  esophageal 
entrance  at  the  larynx  can  be  overcome  by  the  patient  going  through 
the  act  of  swallowing.  It  is  better  that  the  patient  swallow  the 
bucket  before  retiring  at  night  and  that  it  be  withdrawn  in  the 
morning  while  the  stomach  is  empty.  If  the  bucket  has  entered 
the  duodenum,  its  contents  will  be  found  to  be  yellowish,  from  bile. 


Fig.   8 


Duodenal 
bucket. 


92  EXAMINATION  OF  THE  STOMACH  CONTENTS 

We  can  assure  ourselves  of  the  presence  of  the  bucket  in  the  duo- 
denum by  means  of  the  Roentgen  ray. 

MICROSCOPIC  EXAMINATION  OF  STOMACH  CONTENTS. 

Microscopic  examination  may  be  made  of  the  gastric  contents 
as  withdrawn  from  the  stomach  by  the  stomach  tube  after  the 
administration  of  a  test  meal,  or  from  the  vomitus.  Undue  impor- 
tance should  not  be  attached  to  the  presence  of  meat  shreds  (Fig. 
10,  C)  or  starch  granules  (Fig.  9,  C),  which  are  practically  never 
absent  from  the  gastric  juice.  Normal  gastric  juice  may  also 
contain  small  particles  of  mucus,  a  few  bacilli,  and  some  yeast  cells. 

In  motor  insufficiency,  remains  of  food  which  has  been  introduced 
many  hours  previously  may  be  found  in  the  form  of  numerous  fat 
globules  or  fatty  acid  crystals  (Fig.  9,  B  and  E),  vegetable  fibers 
and  plant  cells  (Fig.  9,  D),  as  well  as  a  few  red  blood-corpuscles 
which  have  come  from  abrasion  of  the  pharynx  by  the  stomach 
tube.  Any  red  blood-cells  found  are  apt  to  be  altered  in  appearance 
as  a  result  of  the  action  of  the  hydrochloric  acid  of  the  stomach. 

The  Boas-Oppler  bacillus  (Fig.  10,  B)  is  found  in  75  to  85  per 
cent,  of  all  cases  of  gastric  carcinoma  and  rarely  in  non-malignant 
disease.  It  is  found  more  frequently  when  lactic  acid  is  present 
in  large  amounts,  and  may  be  absent  in  the  incipient  stages  of 
carcinoma.  It  is  3  to  10  microns  in  length  and  1  micron  broad. 
These  bacilli  are  frequently  found  joined  end  to  end,  forming 
very  long  chains.  They  stain  by. the  ordinary  method  as  well 
as  by  Gram's  method,  and  take  on  a  brown  color  when  treated 
with  iodin.  This  latter  feature  distinguishes  them  from  the 
Leptothrix  buccalis,  which  stains  blue  with  iodin.  The  Boas- 
Oppler  bacillus  is  not  infallibly  pathognomonic  of  carcinoma;  it  is 
present  on  rare  occasions  in  the  dilatation  of  benign  stenosis  of  the 
pylorus. 

Sarcinse  are  occasionally  found  in  normal  gastric  juice,  and 
especially  in  cases  of  gastric  dilatation  when  there  is  marked  fermen- 
tation, with  hydrochloric  acid  present;  they  consist  of  cocci  arranged 
in  squares  or  tetrahedra  (Fig.  9,  F),  and  are  of  no  pathologic 
significance  other  than  being  indicative  of  stagnation.  A  large 
number  of  yeast  cells  are  found  along  with  the  sarcinse. 

Mould  fungi  are  occasionally  found  in  the  stomach  contents, 
though  in  the  normal  stomach  they  are  scarcely  to  be  detected, 
since  they  mix  at  once  with  the  chyme  and  are  carried  onward 
through  the  pylorus.  Should  a  colony  of  the  fungi  infest  a  fold  of 
the  surface  of  the  gastric  mucous  membrane,  they  may  become 
so  firmly  adherent  as  to  grow  there  undisturbed.  When  found, 
lavage  of  the  stomach  will  remove  the  mould  flakes.  The  mucous 
membrane  is  not  directly  injured  by  mould  fungi. 

Protozoa  have  been  found  in  the  gastric  contents.     Flagellates, 


MICROSCOPIC    EXAMINATION    OF    STOMACH    CONTENTS    93 


Fig.  9. — A,  epithelial  cells;  B,  fat  globules;  C,  starch  granules;  D,  plant  cells; 
E,  fatty  crystals;  F,  sarcinae. 


Fig.  10. — A,  pus  cells;  B,  Boas-Oppler  bacilli;  C,  muscle  fiber. 


94  EXAMINATION  OF  THE  STOMACH  CONTENTS 

amebse  and  monads  are  among  the  more  frequent  protozoan  types 
found.  According  to  Simon,  "from  the  available  data  there  can 
be  no  question  that  the  presence  of  protozoa  in  the  stomach  contents 
is  suggestive  of  non-obstructive  carcinoma." 

In  cases  of  chronic  gastritis,  ulcer,  hypercHorhydria,  and  espe- 
cially carcinoma,  small  shreds  of  mucous  membrane  are  sometimes 
found  in  the  gastric  contents  withdrawn  by  the  tube.  Such  tissue 
fragments  should  be  carefully  studied  under  the  microscope,  since 
it  is  sometimes  possible  to  make  a  diagnosis  of  carcinoma  thereby. 

Various  types  of  crystals  are  occasionally  noted  in  the  gastric 
contents,  among  which  may  be  mentioned  bile  acids,  cholesterol, 
fatty  acids,  leucin,  tyrosin,  and  calcium  oxalate. 

CHANGES  IN  GASTRIC  SECRETION  DUE  TO  PATHOLOGIC 
CONDITIONS. 

1.  Gastric  Neuroses. — The  gastric  findings  in  nervous  dyspepsia 
show  the  acidity  to  be  normal  or  either  above  or  below;  the  ferments 
are  fairly  constant.  The  fact  that  the  acidity  varies  from  day  to 
day,  being  one  day  excessive  and  the  next  decreased,  is  character- 
istic of  the  disease.  Hemmeter  gave  the  name  "heterochylia"  to 
this  condition.  In  chronic  gastritis  the  acidity  remains  constant, 
while  in  nervous  dyspepsia  it  is  subject  to  variation.  The  ferments, 
which  are  diminished  in  chronic  gastritis,  are  usually  normal  in 
nervous  dyspepsia.  The  findings  in  chronic  gastritis  reveal  much 
mucus,  in  nervous  dyspepsia  little  or  none.  The  former  condition 
is  associated  with  dietetic  errors,  the  latter  with  a  neurotic  tem- 
perament. 

2.  Hyperacidity;  Hyperchlorhydria. — This  term  is  used  to  desig- 
nate the  secretion  of  gastric  juice  of  excessive  acidity,  the  amount  of 
free  hydrochloric  acid  varying  from  a  small  to  a  high  degree  above 
the  normal.  The  normal  acidity  is  between  40  and  60  degrees. 
Usually  an  increased  total  acidity  is  found  along  with  the  increase 
in  free  hydrochloric  acid.  Hyperacidity  is  said  to  exist  when 
there  is  a  constant  of  more  than  60  degrees,  0.2  per  cent,  of 
hydrochloric  acid.  Hyperacidity  or  hyperchlorhydria  may  be  due 
to  neuroses,  or  to  pathologic  changes  in  the  mucous  membrane 
of  the  stomach  itself.  Often  there  is  diminished  motility  due  to 
pylorospasm,  and  as  a  result  stagnation  of  gastric  contents  with 
fermentation.  In  such  cases  the  acidity  may- amount  to  150  degrees 
or  over;  erythrodextrin  is  present  in  large  quantities. 

3.  Hypersecretion;  Gastrosuccorrhea ;  Gastrorrhea ;  Gastrochylorrhea. 
— By  this  is  understood  an  excessive  secretion  of  gastric  juice  in  the 
total  or  almost  total  absence  of  stimulus  to  the  secretory  function 
of  the  stomach.  Hypersecretion,  or  gastrosuccorrhea  as  it  has  been 
called,  is  always  a  pathologic  condition.  The  diagnosis,  as  stated 
elsewhere,  is  confirmed  by  the  finding  of  a  pathognomonic  quantity 


CHANGES  IN  GASTRIC  SECRETION  95 

of  gastric  juice,  containing  both  hydrochloric  acid  and  pepsin,  in 

the  fasting  stomach.  The  quantity  should  be  at  least  I  10  Cc.  before 
the  clinician  is  justified  in  making  a  diagnosis  of  hypersecretion. 
There  is  somewhat  of  an  increase  in  the  degree  of  acidity;  erythro- 
dextrin  and  achroodextrin  are  absent.  There  must  be  no  food  rem- 
nants, sarcina?,  or  yeast  cells.  In  gastric  dilatation  which  may  result 
from  spasm  of  the  pylorus  we  find  fermentation  products,  yeast  cells, 
and  sarcinse. 

4.  Acute  Gastritis. — Examination  of  the  gastric  contents  in  this 
condition  reveals  a  diminished  total  acidity  with  little  or  no  free 
hydrochloric  acid.  The  total  acidity  is  always  below  40  degrees. 
Much  mucus  and  undigested  food  is  apt  to  be  found.  The  hydro- 
chloric acid  secretion  is  either  very  much  diminished  or  entirely 
absent. 

5.  Chronic  Gastritis.- — Examination  of  the  stomach  contents  in 
this  condition  reveals  much  mucus  usually  mixed  with  the  food, 
which  shows  little  signs  of  digestion.  The  quantity  varies  from 
100  to  200  Cc.  Free  hydrochloric  acid  is  diminished  or  absent, 
and  the  gastric  ferments  are  very  much  reduced.  The  total 
acidity  is  below  40  degrees.  Pepsinogen  and  rennin  zymogen  are 
always  present.  Erythrodextrin  is  found  in  small  quantities,  and 
achroodextrin  in  abundance.  The  presence  of  epithelial  cells  and 
leukocytes  is  detected  by  microscopic  examination.  The  finding  of 
large  amounts  of  mucus  in  which  are  mingled  leukocytes  and 
epithelial  cells  is  characteristic  of  chronic  gastritis. 

6.  Achylia  Gastrica. — For  a  diagnosis  of  this  condition  the  Ewald- 
Boas  test  breakfast  may  be  used  with  advantage.  Examination 
of  the  stomach  contents  shows  very  little  change  in  the  ingested 
food.  There  is  usually  a  small  amount  of  fluid  present.  The  food 
has  a  characteristic  appearance,  showing  complete  lack  of  digestion. 
There  is  no  free  hydrochloric  acid,  and  the  total  acidity  is  very 
low,  1  to  6  degrees.  The  gastric  ferments  are  either  very  much 
diminished  or  entirely  absent.  There  is  no  evidence  of  decomposi- 
tion, no  odor,  and  no  mucus.  Erythrodextrin  is  absent.  Lactic 
acid  is  present  in  very  minute  quantity  if  at  all. 

7.  Motor  Insufficiency  (Atony  and  Dilatation).— When  motor  insuf- 
ficiency is  suspected,  a  tablespoonful  of  currants  should  be  given 
to  the  patient  in  the  evening,  to  be  followed  by  a  test  breakfast  the 
next  morning  (see  page  67).  Boiled  rice  may  be  given  instead  of 
currants.  If  either  the  currants  or  the  boiled  rice,  as  the  case  may 
be,  be  found  in  the  fasting  stomach  next  morning  or  removed  with 
the  test  breakfast,  a  diagnosis  of  motor  insufficiency  is  made.  The 
volume  of  the  gastric  contents  is  usually  increased,  so  that,  as  a  rule, 
more  than  180  Cc.  is  found  after  the  test  breakfast.  If  after  a  full 
meal  in  the  evening  visible  food  remnants  are  found  in  the  fasting 
stomach  in  the  morning,  in  all  probability  the  condition  is  one  of 
motor  insufficiency  of  the  second  degree,  inasmuch  as  food  remnants 


96  EXAMINATION  OF  THE  STOMACH  CONTENTS 

are  never  found  in  simple  atony.  The  quantity  of  residue  found  in 
the  stomach  is  an  indication  of  the  motor  power  of  that  organ.  In 
aggravated  cases  of  motor  insufficiency  food  residues  are  often  found 
in  the  stomach  seven  hours  after  the  administration  of  a  test  meal, 
when  the  stomach  under  normal  conditions  would  be  empty.  In 
severe  cases  the  quantity  of  urine  excreted  during  the  twenty-four 
hours  is  markedly  diminished,  whereas  in  atony  or  motor  insuffi- 
ciency of  the  first  degree  it  is  normal.  The  chlorophyl  test  shows 
larger  quantities  of  water  residue  than  when  motility  is  normal. 
Owing  to  the  variability  in  the  gastric  secretion  in  motor  insuffi- 
ciency, chemical  analysis  affords  but  little  aid  to  the  diagnosis.  In 
the  initial  stages  of  gastric  atony  the  secreting  glands  produce  an 
excessive  amount  of  gastric  juice,  followed  by  a  diminution  due 
to  fatigue  of  the  glands.  At  first  the  hydrochloric  acid  may  show 
a  marked  increase,  or  it  may  remain  normal  for  a  long  time.  Some 
cases  of  motor  insufficiency  may,  upon  examination  of  the  gastric 
contents,  show  subacidity  or  anacidity. 

8.  Pyloric  Stenosis. — In  this  condition  there  is  always  retention 
of  food  in  the  stomach.  Should  the  patient  partake  of  mixed  diet 
in  the  evening,  and  the  gastric  contents  be  removed  the  following 
morning,  the  various  food  residues  can  be  recognized  macroscopi- 
cally.  Dilatation  of  the  stomach  always  accompanies  pyloric  steno- 
sis. When  the  obstruction  is  of  benign  origin,  free  hydrochloric 
acid  is  usually  present,  whereas  it  is  usually  absent  in  cases  of 
malignant  origin.  Lactic  acid,  which  is  absent  in  cases  of  benign 
obstruction,  is  usually  found  hi  malignant  obstruction.  In  malig- 
nancy there  is  a  marked  decrease  in  total  acidity  of  the  gastric 
juice,  while  in  benign  obstruction  the  acidity  may  be  increased 
several  degrees.  Rennin,  always  found  in  cases  of  benign  stenosis 
of  the  pylorus,  is  frequently  absent  in  malignant  obstruction.  The 
odor  of  the  gastric  contents  is  more  marked  and  fetid  in  malignant 
than  in  benign  stenosis.  In  the  former  condition  the  Boas-Oppler 
bacillus  is  found,  while  in  benign  cases  it  is  absent.  Sarcinse, 
which  may  be  present  in  benign  stenosis,  are  usually  absent  in  the 
malignant  form.  In  pyloric  stenosis  the  gastric  contents,  if  with- 
drawn and  allowed  to  stand  in  a  glass,  will  separate  out  so  as  to 
form  three  layers  or  strata.  The  upper  layer  is  frothy,  due  to 
decomposition;  the  middle  layer  is  clear  or  slightly  cloudy;  the 
lowest  layer  is  semisolid. 

9.  Pyloric  Insufficiency. — The  diagnosis  of  this  condition  is  con- 
firmed when  the  stomach  is  found  empty  after  the  administration 
of  the  Ewald-Boas  test  breakfast.  The  degree  of  pyloric  insuffi- 
ciency is  ascertained  by  administering  test  meals  on  successive  days 
and  removing  the  contents  at  stated  intervals,  such  as  three-quarters 
of  an  hour,  half  an  hour,  and  fifteen  minutes,  after  the  ingestion 
of  the  test  meal.  Chemical  analysis  of  the  gastric  secretion  may 
reveal  the  presence  of  hydrochloric  acid,  pepsin,  and  rennin,  or 
these  may  be  absent.    The  ready  passage  of  air  from  the  stomach 


CHANGES  IN  GASTRIC  SECRETION  97 

tube  through  the  stomach  into  the  duodenum  points  to  insufficiency 

of  the  pylorus. 

10.  Gastric  Ulcer. — The  clinieal  symptoms  are  of  greater  impor- 
tance than  examinaton  of  gastric  contents  in  the  diagnosis  of  this 
condition.  The  use  of  the  stomach  tube  is  obviously  inadvisable 
when  ulceration  is  suspected.  The  vomitus  consists  of  well-digested 
food,  which  may  or  may  not  be  free  from  blood.  If  blood  be 
present,  it  will  be  either  of  a  fresh  red  color  or  dark.  The  total 
acidity,  of  which  free  hydrochloric  acid  constitutes  the  major 
portion,  is  usually  increased;  at  times  it  may  be  three  times  the 
normal — up  to  180  degrees.  The  test  for  occult  blood  will  usually 
reveal  it  in  the  feces.     (Plate  IX.) 

11.  Erosions  of  the  Stomach. —  In  this  condition  examination  of 
the  returned  water  from  gastric  lavage  reveals  small  fragments 
of  mucous  membrane  which,  under  the  microscope,  show  blood 
corpuscles  and  gastric  glands,  the  form  of  which  is  apt  to  be  well 
preserved  and  distinct.  These  fragments  of  gastric  mucosa  are 
constantly  found  when  the  patient's  stomach  is  washed  out  in  the 
fasting  condition  (Einhorn).  In  perhaps  the  majority  of  cases  of 
gastric  erosion  there  is  a  decrease  in  the  hydrochloric  acid  secretion. 
On  rare  occasions,  on  the  other  hand,  hyperacidity  may  exist. 
Mucus  is  present  in  greater  or  less  quantity. 

12.  Gastric  Carcinoma. — In  this  condition  examination  of  the 
stomach  contents  yields  certain  results  suggestive  of  the  disease. 
Among  these  is  the  absence  of  free  hydrochloric  acid.  This  is 
among  the  early  symptoms  in  perhaps  90  per  cent,  of  all  cases,  but 
is  subject  to  marked  variations  from  day  to  day.  The  total 
acidity,  as  well  as  the  amount  of  free  hydrochloric  acid,  is  dimin- 
ished. Free  hydrochloric  acid  may,  however,  be  present  in  normal 
or  more  than  normal  amounts  when  the  carcinoma  is  small  and 
ulcerous  and  occupies  the  pyloric  region. 

The  presence  of  lactic  acid,  increased  in  amount,  is  also  suggestive 
of  carcinoma  of  the  stomach;  90  per  cent,  of  cases  show  lactic  acid 
present  as  well  as  free  hydrochloric  acid  absent.  In  testing  for  lactic 
acid  the  contents  of  the  fasting  stomach  should  be  examined  in 
the  morning,  after  thorough  gastric  lavage  the  night  before.  In 
carcinomatous  cases  this  examination  will  show  very  slight  digestion 
of  proteins,  with  fairly  good  digestion  of  carbohydrates.  The 
finding  of  arninoacids  in  the  gastric  contents  is  important.  The 
microscope  may  show  fragments  of  the  neoplasm,  such  as  cellular 
masses,  embedded  in  blood — a  very  definite  diagnostic  sign.  The 
cytodiagnosis  is  very  helpful.  The  Boas-Oppler  bacillus  (Fig.  10,  B) 
is  said  to  occur  in  75  to  85  per  cent,  of  carcinomatous  patients 
and  is  rarely  found  in  any  other.  The  test  for  occult  blood  in  the 
feces  is  usually  positive.  The  "Wolfi-Junghans  test  is  very  valuable 
in  conditions  of  achlorhydria  (see  page  87).  Gluzinski's  test  is 
usually  positive  (see  page  88). 
7 


CHAPTER  III. 
EXAMINATION  OF  THE  DUODENAL  CONTENTS. 

With  the  discovery  that  the  contents  of  the  stomach  could  be 
removed  at  any  stage  in  the  process  of  digestion,  by  inserting  a 
rubber  tube  and  applying  suction  or  the  siphon  principle,  the  diag- 
nosis of  diseases  of  the  stomach  by  examination  of  its  contents 
assumed  an  importance  of  the  first  rank.  Then,  as  the  stomach 
tube  demonstrated  its  value,  the  question  arose:  Why  not  also 
examine  the  secretions  of  other  organs  concerned  in  digestion? — 
particularly  the  pancreas,  which  was  known  to  be  of  much  greater 
importance  in  the  process  of  digestion  than  the  stomach. 

In  1897  Hemmeter  described  an  apparatus  by  which  he  was 
able  to  introduce  instruments  into  the  duodenum.  It  consisted  of 
a  tube  connected  with  a  rubber  bag  the  shape  of  the  stomach, 
grooved  on  its  upper  surface  for  the  passage  of  another  tube  into 
the  duodenum  through  the  pylorus  after  the  bag  had  been  intro- 
duced and  filled  with  air.  The  difficulty  with  this  instrument  is 
that  stomachs  vary  in  size  and  configuration.  One  cannot  obtain 
in  advance  a  mold  of  any  particular  stomach  so  that  the  bag  will 
tally  exactly  with  its  shape,  and  therefore  it  is  impossible  to  say 
beforehand  whether  the  exit  of  the  groove  in  the  bag  is  opposite  the 
pylorus  or  not. 

One  year  later  Kuhn  endeavored  to  reach  the  duodenum  directly 
by  means  of  specially  constructed  tubes  with  a  metal  spiral  inside. 
The  spiral  served  to  prevent  too  much  bending  and  kinking  under 
pressure.  He  took  a  long  stomach  tube,  put  the  metal  spiral  inside, 
and  manipulated  it  for  a  long  time,  until  he  reached  the  duodenum. 
Kuhn's  tube  did  not  differ  much  from  the  ordinary  stomach  tube  and 
was  never  practical. 

Einhorn  Duodenal  Tube. — The  credit  for  aspirating  the  duodenal 
contents  is  due  to  Einhorn,  who  in  1909  employed  a  small  rubber 
tube  ending  in  a  perforated  metal  capsule  (Fig.  11,  a).  For  aspirat-. 
ing  the  duodenal  contents  this  device  is  more  practical  than  the 
duodenal  bucket  (see  page  91).  The  main  principle  of  the  Ein- 
horn duodenal  tube  is  to  allow  the  stomach  to  do  the  work  of  push- 
ing the  tube  through  the  pylorus.  The  terminal  capsule  is  14 
millimeters  long  and  23  millimeters  in  circumference,  and  can  be 
unscrewed  for  cleansing.  It  communicates  with  a  long,  thin  rubber 
tube  (8  millimeters  in  circumference  and  one  meter  long),  marked 
at  40  cm.  (I,  cardia),  56  cm.  (II,  pylorus),  70  cm.  (Ill),  and  80 


EIXJIORX  DLODKXAL  TV  HE 


99 


cm.  distant  from  the  capsule.  At  the  free  end  of  the  tube  is  a  tip 
to  which  a  syringe  can  be  easily  attached  I  Fig.  83).  This  apparatus 
can  be  used  for  aspirating  either  gastric  or  duodenal  contents. 
For  the  latter  purpose  it  is  introduced  in  the  same  manner  as  for 


Fig.  11. — a,  Einhorn  duodenal  tube;  b,  Gross  duodenal  tube;  c,  Palefski  duodenal 
tube;  d,  Jutte  duodenal  tube. 


duodenal  feeding,  as  described  on  page  500.  After  the  syringe  is 
filled  with  the  duodenal  contents,  the  tube  is  clamped  and  slowly 
withdrawn.  When  the  capsule  reaches  the  level  of  the  cricoid 
cartilage  the  patient  is  told  to  swallow,  and  during  this  act  the 
capsule  is  withdrawn.     (Plate  V.) 


100  EXAMINATION  OF  THE  DUODENAL  CONTENTS 

Gross  Duodenal  Tube.— The  Gross  duodenal  tube  is  somewhat 
similar  to  Einhorn's,  except  that  it  has  a  mult  iperf orated  silver- 
plated  leaden  ball  weighing  10  grams  at  its  distal  end,  covered 
by  the  tube  on  all  sides  (Fig.  11,  b).  This  heavy  end  facilitates  the 
passage  of  the  tube  through  the  pylorus.  In  detail  the  technic  of 
introducing  the  Gross  tube  is  as  follows:  The  fasting  patient  sits 
in  a  chair  and  with  the  aid  of  a  little  water  swallows  the  metal  end 
of  the  tube;  then,  breathing  rhythmically,  he  simply  allows  the  tube 
to  pass  in  up  to  the  45-centimeter  mark;  then  he  holds  it  fast  with 
his  lips,  bends  forward  a  moment,  and  lies  on  his  right  side,  with 
raised  upper  body.  The  tube  is  then  held  lightly  between  the 
fingers  and  is  fed  into  the  stomach  up  to  the  70-centimeter  mark; 
it  is  not  shoved  in,  but  allowed  to  follow  the  pull  of  the  heavy  metal 
end  and  of  the  respiratory  movements.  Then  gastric  juice  is 
aspirated  and  tested  for  its  reaction.  The  patient  remains  five 
minutes  longer  on  the  right  side,  with  the  tube  held  fast  between 
the  lips;  he  then  rolls  over  on  his  back,  and  two  pillows  are  placed 
under  his  hips.  Five  minutes  later  the  tube  is  inserted  to  the 
80-centimeter  mark.  After  another  five  minutes  (often  earlier)  the 
aspirated  fluid  is  neutral  or  alkaline  and  thus  found  to  be  from  the 
duodenum.  To  aid  the  passage  of  the  duodenal  tube,  percussion  of 
the  fifth  dorsal  vertebra  is  helpful  (see  page  211).  This  pyloric 
reflex  opens  the  pylorus,  while  the  stomach  forces  the  weighted  end 
of  the  tube  into  the  duodenum. 

Palefski  Duodenal  Tube. — The  Palefski  tube  has  a  gold-plated 
leaden  ball  at  its  distal  end  (Fig..  11,  c),  and,  like  the  Gross  tube, 
passes  into  the  stomach  and  through  the  pylorus  by  the  force  of 
gravity. 

Jutte  Duodenal  Tube.— The  Jutte  tube  has  a  lead  sinker  at  its 
distal  end,  and  perforations  in  the  soft-rubber  tube  above  it 
(Fig.  11,  d).  A  wire  obturator  assists  in  the  rapid  passage  of  the  tube, 
which  is  accomplished  in  much  the  same  manner  as  the  passage  of 
an  ordinary  stomach  tube. 

Determination  of  Tube  in  Duodenum. — To  determine  whether  the 
tube  is  in  the  stomach  or  the  duodenum,  aspirate,  and  if  you  find 
that  the  fluid  comes  out  quickly  and  looks  watery,  that  hydro- 
chloric acid  is  present,  that  Congo  paper  turns  blue,  dimethyl- 
amidoazobenzol  red,  and  litmus  paper  red,  you  know  the  tube  is 
in  the  stomach;  if,  on  the  contrary,  you  get  only  very  little  fluid, 
of  neutral  or  alkaline  reaction  and  golden  yellow  color,  you  know 
it  is  in  the  duodenum.  Sometimes  a  patient  has  no  hydrochloric 
acid  in  the  gastric  contents,  and  the  achlorhydria  may  lead  to  the 
inference  that  the  tube  is  in  the  duodenum.  Under  such  circum- 
stances have  the  patient  drink  some  milk,  and  aspirate;  if  the 
milk  is  not  obtainable  immediately  after  drinking,  it  will  be  known 
that  the  tube  is  in  the  duodenum.  Conclusive  proof  is  afforded  by 
drawing  the  tube  up  a  short  distance  and  again  aspirating,  when, 


PLATE    LV 


Duodenal  Tube  in  the  Duodenum,  with  Perforated  Metal 
Capsule  Near  the  Papilla  of  Vater. 


TEST  MEAL  101 

the  terminal  capsule  having  re-entered  the  stomach,  you  will  obtain 
the  milk  that  the  patient  has  just  swallowed.  If  the  patient  has 
had  milk  before  the  test,  substitute  raspberry  syrup  as  an  indicator. 
If  necessary,  a  Roentgen-ray  inspection  can  be  made. 

Characteristics  of  Duodenal  Contents.  —  The  duodenal  contents 
usually  consist  of  pancreatic  juice,  bile,  and  some  duodenal  secre- 
tion proper.  The  mixture  normally  has  a  golden  yellow  hue,  is 
limpid,  viscid,  and  alkaline  to  litmus  and  methyl  orange  (alka- 
linity =  about  20),  but  rather  acid  to  phenolphthalein.  Ordinarily, 
after  standing  a  few  hours,  the  yellow  color  loses  much  of  its  bright- 
ness and  becomes  slightly  greenish  and  turbid.  The  fresh  contents 
have  no  particular  odor,  but  with  the  change  in  appearance  an 
unpleasant  odor  develops,  which  rapidly  increases  in  intensity; 
this  result  is  due  to  decomposition,  or  rather  putrefaction,  through 
the  action  of  bacteria.  Finally  the  odor  becomes  fetid,  resembling 
feces. 

Urobilin  and  Urobilinogen. — The  excretion  of  urobilin  and  urobili- 
nogen in  the  duodenal  contents  is  definitely  increased  in  hemolytic 
anemias.  Schlesinger's  method  of  testing  for  these  substances  is  as 
followrs:  To  10  Cc.  of  the  duodenal  contents  an  equal  amount  of  a 
saturated  alcoholic  solution  of  zinc  acetate  is  added.  After  being 
thoroughly  mixed  by  vigorous  shaking,  the  w' hole  is  filtered  through 
coarse  filter  paper.  To  10  Cc.  of  this  filtrate,  1  Cc.  of  Ehrlich's 
aldehyde  reagent  is  added  with  a  pipet.  If  urobilinogen  is  present 
the  fluid  becomes  cherry  red,  and  when  there  is  a  preponderance  of 
urobilin  the  color  by  transmitted  light  is  yellow  or  brown.  The 
liquid  is  allowed  to  stand  fifteen  minutes  and  is  then  examined  spec- 
troscopically.  Urobilin  is  marked  by  a  broad  band  in  the  blue  end, 
wThile  urobilinogen  absorbs  a  narrow  portion  of  the  spectrum  in  the 
yellow  at  the  edge  of  the  green  and  if  present  in  large  amounts  may 
obliterate  the  entire  yellow  portion  of  the  spectrum. 

Test  Meal. — Einhorn  has  devised  a  test  meal  for  use  in  connection 
with  the  examination  of  the  duodenal  contents,  similar  to  the  test 
breakfast  for  examination  of  the  gastric  juice.  Inasmuch  as  the 
duodenal  tube  has  a  narrow7  lumen,  solid  food  would  clog  up  the 
instrument  and  is  therefore  inappropriate  for  such  a  test.  The  test 
meal  consists  of  one  bouillon  cube  to  one  cup  of  hot  water.  Bouillon 
contains  the  beef  extractives  wThich  act  as  a  strong  stimulant  to  the 
digestive  secretions.  In  all  pancreatic  affections  and  other  digestive 
disturbances  in  the  duodenum  it  is  best  to  examine  the  duodenal 
contents  from  one  to  one  and  a  half  hours  after  the  bouillon  test 
meal.  The  pancreatic  secretions  are  at  their  best  in  an  alkaline 
medium,  and  there  should  be  no  acid  gastric  contents  in  the  duo- 
denum when  the  duodenal  contents  are  withdrawn.  In  pathologic 
lesions  we  may  have  conditions  in  which  the  degree  of  alkalinity  is 
too  high  or  too  low. 

For  the  diagnosis  of  fiver  and  gall-bladder  lesions  it  is  better  to 


102  EXAMINATION  OF  THE  DUODENAL  CONTENTS 

examine  the  duodenal  contents  while  the  patient  is  fasting — that  is 
to  say,  without  a  test  meal.  The  bile  is  then  in  as  pure  a  state  as 
we  can  obtain  it  for  this  purpose. 

Examination  for  Enzymes. — Besides  testing  the  duodenal  contents 
for  reaction  (neutral,  acid,  or  alkaline),  specific  gravity,  appear- 
ance, and  admixture  of  mucus,  the  principal  point  of  importance 
is  to  ascertain  the  presence  or  absence  of  the  three  pancreatic  fer- 
ments, amylopsm,  steapsin,  and  trypsin,  and  if  possible  the  approxi- 
mate quantity  of  each.  Einhorn  with  his  agar  tubes  (Plate  IV)  has 
made  it  possible  for  us  to  follow  one  uniform  method  of  examination, 
so  that  comparisons  may  be  easily  made  and  the  results  accurately 
tabulated. 

Einhorn's  agar  tubes  are  made  as  follows: 

Starch  Agar  Tubes. — Agar  powder,  2.5  Gm.;  starch,  5  Gm.;  dis- 
tilled water,  to  100  Cc.  Rub  the  starch  and  agar  in  a  mortar 
with  sufficient  water  to  make  a  smooth  paste,  then  add  the  bal- 
ance of  the  water.  This  mixture  is  put  into  a  flask  and  heated  to 
the  boiling-point.  It  is  then  drawn  by  suction  into  a  capillary 
glass  tube  (inside  diameter,  1.5  millimeters)  which  has  previously 
been  warmed  in  the  flame.  The  tube  and  contents  are  allowed  to 
cool  and  are  then  cut  into  3-centimeter  lengths.  These  are  sealed 
at  each  end  with  melted  paraffin.    (Plate  IV,  A.) 

Olive  Oil  Agar  Tubes. — Olive  oil,  25  Cc;  agar  powder,  2  Gm.; 
aqueous  solution  of  Nile-blue  sulphate  (1:2000),  sufficient  to  make 
100  Cc.  Rub  the  olive  oil  and  agar  together,  add  sufficient  water 
to  make  a  thin  paste,  and  add  the  Nile-blue  sulphate  solution  up 
to  100  Cc.  Then  proceed  the  same  as  with  the  starch  tubes.  (Plate 
IV,  B.) 

Hemoglobin  Agar  Tubes.  —  Hemoglobin  powder,  1  Gm.;  agar 
powder,  2.5  Gm.;  distilled  water,  sufficient  to  make  100  Cc.  Rub 
the  hemoglobin  with  about  10  Cc.  of  water  until  it  is  smooth;  add 
the  agar  powder  and  the  balance  of  the  water;  then  proceed  hi  the 
same  manner  as  with  the  starch  tubes.     (Plate  IV,  C.) 

The  agar  tubes  are  best  kept  on  ice  until  used.  They  retain 
their  efficiency  for  a  month  or  six  weeks,  when  they  begin  to  deteri- 
orate. When  they  become  dry  they  are  apt  to  give  misleading 
results. 

Mode  of  Procedure. — Take  one  tube  of  each  kind,  starch,  oil 
and  hemoglobin,  scrape  off  the  paraffin  at  one  end,  and  place  the 
tubes  vertically,  denuded  end  down,  into  a  bottle  containing  a 
small  quantity  of  the  duodenal  secretion  (Plate  IV,  D).  Add  a  few 
drops  of  toluol,  and  keep  the  bottle  in  a  thermostat  at  blood  tem- 
perature for  sixteen  to  twenty-four  hours.  (Einhorn  uses  a  Freas 
electric  oven.)  At  the  end  of  this  time  the  tubes  are  taken  out 
of  the  bottle,  wiped  off,  and  inspected.  The  starch  column  is 
colorless  as  far  upward  as  the  amylopsin  has  acted  upon  it,  con- 
verting  it   into    sugar;   the   distance   is   recorded   in    millimeters 


PLATE    V 


B 


D 


Agar  Tubes  for  Testing   Duodenal   Contents. 

A,  starch  agar  tube;  B,  olive  oil  agar  tube;  C,  hemoglobin  agar  tube;  D,  bottle 
containing  duodenal  contents  and  agar  tubes  ready  for  the  thermostat;  E.  starch 
agar  tube  after  action  of  amylopsin  and  dipping  into  iodin  solution:  F.  olive  oil 
agar  tube  after  action  of  steapsi  n ;     G.  hemoglobin  agar  tube  after  action   of  trypsin. 


30 


JO 


CHANGES  IN  PATHOLOGIC  CONDITIONS  103 

(Plate  IV,  E).  The  starch  column  is  further  examined  by  pushing 
it  out  and  dipping  it  into  a  weak  iodin  solution.  The  hemoglobin 
tube  shows  a  change  of  appearance  (due  to  the  action  of  the 
trypsin),  the  lower  end  having  become  more  or  less  transparent 
(Plate  IV,  G).  The  oil  tube  has  a  bluish  appearance  at  the  lower 
end,  the  steapsin  having  split  the  oil  into  fatty  acids  producing 
this  color  (Plate  IV,  F).  The  extent  of  the  transparency  in  the  hemo- 
globin tube  and  of  bluish  color  in  the  oil  tube  are  measured  and 
stated  in  millimeters.  Thus  the  starch  serves  to  gauge  the  amy- 
lopsin,  the  olive  oil  the  steapsin,  and  the  hemoglobin  the  trypsin 
ferments. 

Determination  of  Enzymes.  —  The  duodenal  ferments  in  normal 
individuals,  as  determined  by  Einhorn  and  measured  hi  milli- 
meters on  the  capillary  tube  (Fig.  12),  fluctuate  as 
follows:  Amylopsin,  4  to  8  mm.;  steapsin,  2  to  5 
mm.;  trypsin,  0.5  to  5  mm.  The  average  figures  are: 
Anivlopsin,  6  mm.  (Plate  IV,  E);  steapsin,  3.5  mm. 
(Plate  IV,  F);  trypsin,  2.8  mm.  (Plate  IV,  G). 

Changes  in  Pathologic  Conditions. — In  pathologic 
conditions  there  is  a  noticeable  independence  among 
the  three  different  ferments  with  regard  to  quantity 
in  the  same  individual :  one  ferment  may  be  present 
in  large  amount  and  the  other  two  in  small  amoimt  FiG  12  _Milli. 
or  not  at  all.  It  is  therefore  necessary  to  test  for  meter  scale, 
each  of  the  three  ferments  separately.  This  is  ac- 
complished most  conveniently  by  means  of  the  agar  tubes  (Plate  IV). 

The  pancreatic  secretion  is  subject,  like  the  gastric  juice,  to  func- 
tional anomalies,  or  deviations  from  the  normal.  It  may  contain 
an  overabundance  of  ferments  or  too  small  a  quantity.  ^Tiile  in 
the  case  of  the  gastric  juice  the  functional  activity  is  usually  reck- 
oned by  the  amount  of  hydrochloric  acid  present,  we  have  not 
been  able  as  yet  to  select  any  one  of  the  three  pancreatic  ferments 
for  reckoning  purposes.  However,  trypsin  being  the  most  impor- 
tant ingredient  of  the  pancreatic  juice,  it  would  seem  natural  to 
use  it  as  a  gauge  for  the  functional  activity  of  this  gland.  According 
to  Einhorn,  the  following  terms  may  be  advantageously  used: 

Eupancreatism :  Normal  f miction;  all  three  ferments  present, 
trypsin  showing  the  normal  quantity  (1  to  4  millimeters). 

Hyperpancreatism:  Increased  activity;  all  three  ferments  present, 
trypsin  existing  in  excers  (above  4  millimeters). 

Hypopancreatism :  Diminished  activity;  the  three  ferments  present, 
trypsin  decreased  (below  1  millimeter). 

Dyspancreatism:  Disturbed  function;  one  or  two  of  the  three 
ferments  are  absent. 

Heteropancreatism :  Varied  function;  the  presence  and  amoimt 
of  ferments  showing  no  constancy,  but  varying  from  time  to  time. 

In  addition  to  those  connotations  on  the  pancreatic  juice  which 


104  EXAMINATION  OF  THE  DUODENAL  CONTENTS 

refer  to  degrees  of  ferment  activity,  we  must  distinguish  differ- 
ences in  quantity  also.  There  is,  then,  normal  pancreatic  secre- 
tioD,  or  euchylia  pancreatica;  too  much  secretion,  or  Iryperchylia 
pancreatica;  and  too  little  secretion,  or  hypochylia  pancreatica. 
Achylia  pancreatica  signifies  that  there  is  no  pancreatic  juice  at  all. 

Exact  knowledge  of  the  state  of  pancreatic  activity  in  the  patient 
will  often  assist,  in  conjunction  with  other  symptoms,  in  the  diag- 
nosis of  functional  or  organic  disease  of  this  gland.  Moreover,  it  is 
always  helpful  in  formulating  an  appropriate  diet  for  any  given 
case  no  matter  from  what  disease  the  patient  may  be  suffering. 

Direct  Medication — The  duodenal  tube  may  be  used  for  direct 
medical  application  to  the  mucous  membrane  of  the  upper  intestinal 
tract.  It  has  been  found  that  instillation  of  medication  into  the 
duodenum  will  not  only  improve  inflammatory  processes  present 
but  also  act  beneficially  on  the  mucous  membrane  of  the  common 
bile  duct,  gall  bladder,  and  pancreas.  Cholecystitis  will  often 
yield  to  instillation  into  the  duodenum,  every  day,  of  15  Cc.  of 
either  a  0.5-per-cent.  solution  of  argyrol  or  a  1-per-cent.  solution  of 
ichthyol.  A  turbid  bile  means  a  probable  cholecystitis.  In  the 
treatment  of  cholecystitis,  direct  application  of  solutions  of  argyrol 
and  ichthyol  can  easily  be  made  through  the  duodenal  tube  to  the 
duodenum  just  above  the  ampulla  of  Vater. 

Draining  the  Gall  Bladder  and  Bile  Ducts. — "When  surgeons  find  an 
inflammation  of  the  gall  bladder  on  removing  gallstones,  they  are 
in  the  habit  of  draining  the  gall  bladder.  Favorable  results  are 
attained  by  cholecystostomy  in  cases  of  cholangeitis,  choledochitis, 
and  cholecystitis.  Meltzer  found  that  a  25-per-cent.  solution  of 
magnesium  sulphate  poured  directly  on  the  mucous  membrane  of  the 
duodenum  caused  complete  local  relaxation  of  the  intestinal  wall. 
It  may  relax  the  sphincter  of  the  common  duct  sufficiently  to  permit 
the  ejection  of  bile,  or  even  the  removal  of  a  calculus  of  moderate 
size  wedged  in  the  duct  in  front  of  the  papilla  of  Vater.  Lyon1  has 
clinically  verified  the  scientific  results  of  Meltzer,  so  that  we  may 
now  not  only  relax  the  sphincter  of  the  common  bile  duct  and  thereby 
drain  all  the  ducts  but  also  cause  the  gall  bladder  to  be  compressed 
and  empty  its  contents  (see  Law  of  Contrary  Innervation,  page 
65).     It  is  thus  possible  to  differentiate  and  study: 

1.  The  first  bile  from  the  common  duct. 

2.  The  second,  darker  and  more  viscous  bile,  from  the  gall  bladder. 

3.  The  third,  clear  golden  bile,  from  the  hepatic  duct. 

We  can  thus  make  a  differential  diagnosis  between  cholecystitis 
and  choledochitis. 

After  the  tube  is  in  the  duodenum  100  Cc.  of  25-per-cent.  mag- 
nesium sulphate  is  allowed  to  flow  by  gravity  into  the  duodenum. 
In  two  to  ten  minutes  bile  will  be  recovered  which  will  be  recognized 

1  B.  B.  Vincent  Lyon:  Can  the  Gall  Bladder,  Biliary  Ducts  and  Liver  be  Medically 
Drained?     American  Journal  of  the  Medical  Sciences  October,  1920. 


DUODENAL  LAVAGE  L05 

by  its  light  yellow  color.  To  quote  i'rmn  Lyon:1  "This  first  bile 
may  be  from  10  to  20  Cc.  in  amount  and  may  require  from  one  to 
three  minutes  to  aspirate,  when  a  sudden  transition  appears  (seen 
first  in  the  glass  window  of  the  tube)  and  the  bile  becomes  darker, 
more  viscid  and  more  concentrated,  and,  in  normal  gall  bladders, 
remains  transparent  but  is  more  of  a  molasses  yellow.  We  believe 
this  type  of  bile  to  be  that  stored  up  in  and  delivered  from  the  gall 
bladder,  and  when  it  appears  first  in  the  glass  window  the  second 
sterile  bottle  is  detached  and  replaced  by  a  third  sterile  collecting 
bottle  into  which  the  bile  is  allowed  to  flow  until  all  of  this  darker 
bile  (more  viscid,  transparent  or  turbid)  has  been  collected  and  is 
being  replaced  by  a  lighter  yellow,  thinner  and  usually  transparent 
bile  which  is  aspirated  much  more  slowly  and  intermittently,  and 
which  we  believe  to  be  bile  freshly  secreted  from  the  liver."  It  will 
thus  be  seen  that  in  duodenal  lavage  with  a  solution  of  magnesium 
sulphate  (see  page  106)  we  have  a  method  for  the  relief  of  biliary 
stasis,  the  forerunner  of  cholecystitis  and  cholelithiasis,  and  also  a 
rational  treatment  for  these  diseases  if  they  are  present. 

Oxygen  Insufflation. — Oxygen  insufflation  has  been  found  very 
useful  as  an  intestinal  antiseptic  measure.  Bacterial  proliferation 
in  the  intestine  can  be  inhibited  by  insufflation  of  pure  oxygen 
through  the  duodenal  tube  into  the  duodenum.  Schmidt  has 
found  this  method  of  treatment  in  intestinal  fermentative  dys- 
pepsia very  satisfactory.  Equally  favorable  results  are  obtained 
in  cases  of  intestinal  putrefaction.  Oxygen  exerts  a  directly 
destructive  effect  on  all  anaerobic  bacteria;  and  when  introduced 
into  the  intestine  in  the  manner  mentioned,  there  can  be  no  dodg- 
ing the  issue.  The  technic  of  oxygen  insufflation  is  described  on 
page  679. 

Duodenal  Lavage.  —  Duodenal  lavage  was  first  practiced  and 
described  by  M.  Ernest  Jutte,  of  New  York.  It  is  to  the  small 
intestine  what  an  enema  is  to  the  colon.  In  applying  duodenal 
lavage  the  apparatus  employed  must  enable  the  practitioner  to 
bridge  the  stomach,  so  that  the  irrigating  fluid  will  not  enter  that 
organ  but  go  directly  into  the  duodenum,  thus  avoiding  vomiting. 

The  outfit  required  consists  of  a  thin  rubber  duodenal  tube,  an 
aspirating  bottle,  a  suction-pump  or  an  ordinary  syringe,  an  irri- 
gator and  rubber  connections;  and  if  the  patient  finds  it  difficult  to 
swallow  the  tube,  a  thin  wire  is  fitted  into  it  to  serve  as  a  guide 
(Fig.  13). 

Duodenal  lavage  should  be  done  when  the  patient's  stomach  is 
empty.  The  technic  of  the  operation  is  as  follows:  The  tube  is 
first  moistened,  then  either  swallowed  or  introduced  manually  as 
far  as  the  "III  ring"  mark;  if  the  manual  method  is  adopted,  the 
wire  obturator  must  first  be  pushed  down  inside  the  tube  as  far  as 

1  B.  B.  Vincent  Lyon,:  Diagnosis  and  Treatment  of  Diseases  of  the  Gall  Bladder 
and  Biliary  Ducts,  Journal  of   American  Medical  Asssciation,  Sept.  27,  1919. 


106 


EXAMINATION  OF  THE  DUODENAL  CONTENTS 


it  will  go — that  is  to  say,  to  the  lead  sinker.  The  patient  drinks  a 
tumblerful  of  water  and  lies  down  on  his  right  side.  Gravity  car- 
ries the  heavy  sinker  near  the  pylorus,  and  peristalsis  soon  pushes 
it  through  along  with  the  water — in  the  course  of  two  or  three 
minutes,  usually.  Connections  are  then  made  between  tube  and 
aspirating  bottle,  and  between  bottle  and  suction  apparatus. 
Exhaust  the  air  from  the  bottle  with  a  large  syringe;  the  suction 
will  soon  result  in  the  appearance  of  diluted  duodenal  secretion  in  the 
aspirating  bottle.  Examination  of  this  fluid  makes  it  clear  that  the 
tube  has  passed  through  the  pylorus  into  the  duodenum  (Plate  V). 
The  patient  can  now  sit  up.  Disconnect  the  suction  bottle  and 
connect  the  tube  with  the  container  holding  the  irrigating  fluid. 
Allow  500  to  1000  Cc.  (1  to  2  pints)  to  trickle  through  the  tube, 
taking  fifteen  minutes  for  this  procedure.  Should  the  patient  com- 
plain of  any  discomfort,  stop  the  drip  for  a  while.  The  entire  quan- 
tity of  fluid  will  have  reached  the  duodenum  in  ten  to  fifteen  min- 


Fig.  13. — Jutte's  apparatus  for  duodenal  lavage. 

utes,  peristalsis  pushing  it  gradually  onward  so  that  there  will  be 
no  distention  in  any  part  of  the  bowel.  To  make  certain  of  this, 
the  flow  can  be  interrupted  every  few  minutes.  After  the  desired 
quantity  of  liquid  has  been  introduced,  the  tube  is  gently  with- 
drawn during  respiration  and  the  patient  is  allowed  to  rest. 

Character  of  Irrigating  Fluid. — Each  case  will  determine  the  kind 
of  fluid  that  is  best  to  use.  In  nervous  disorders,  general  malaise, 
anemia,  rheumatism,  indicanuria- — in  short,  whenever  it  is  desired 
to  cleanse  the  bowel  thoroughly — Jutte  has  found  that  a  solution 
containing  9  grams  each  of  sodium  chlorid  and  sodium  sulphate  to 
1000  Cc.  (1  quart)  of  water  passes  through  the  bowel  without 
being  absorbed  and  acts  excellently  as  an  irrigant.  Duodenal 
lavage  thus  flushes  out  the  entire  length  of  the  intestinal  canal 
from  the  pylorus  to  the  rectum;  it  removes  toxins  of  every  nature, 
and  restores  by  simple  cleansing  of  the  intestinal  tract  the  local 
conditions  necessary  for  normal  health. 

Plain  distilled  water  induces  a  very  copious  diuresis,  thus  flush- 


BACTERIOLOGY  OF  THE  DUODENUM  107 

iiig  out  the  kidneys.  In  icterus  and  when  fat  digestion  is  impaired 
the  addition  of  0.5  Gm.  (7',  grains)  of  pure  Castile  soup  to  L000 
Cc.  (1  quart)  of  saline  is  beneficial.     To  withdraw  fluid  from  the 

body  tissues,  a  stronger  solution  than  normal  saline  will  be  found 
necessary.  By  placing  a  thermometer  against  the  tube  near  the 
patient's  mouth  the  temperature  of  the  fluid  can  be  easily  regu- 
lated so  that  it  will  enter  the  intestine  at  body  heat.  The  bowels 
usually  move  freely  within  one  or  two  hours  after  each  duodenal 
lavage.  When  it  is  desired  to  drain  the  bile  ducts  and  gall-bladder, 
100  Cc.  of  a  25-per-cent.  solution  of  magnesium  sulphate  should  be 
employed  (see  page  695) . 

Indications  for  Duodenal  Lavage. — Considering  that  so  many  dis- 
eases are  caused  by  intestinal  toxemia,  Jutte  believes  that  flushing 
out  the  toxins  from  the  intestine  gives  good  results  in  such  cases 
as  rheumatism,  gout,  sciatica,  arthritis  deformans,  functional  dis- 
orders of  the  heart,  arteriosclerosis,  nephritis,  toxemia  of  preg- 
nancy, cirrhosis  of  the  liver,  intestinal  stasis,  primary  and  secon- 
dary anemia,  skin  diseases,  catarrhal  inflammation  of  the  mucous 
membranes,  mucous  colitis,  asthma,  pernicious  anemia,  neuroses, 
neuralgia,  neuritis,  insomnia,  epilepsy,  neurasthenia,  melancholia, 
dementia  and  insanity. 

In  the  practice  of  duodenal  lavage  I  have  not  had  a  single  failure 
as  regards  the  clinical  cure  of  intestinal  stasis,  and  incidentally  also 
of  constipation,  although  the  anatomical  conditions  (kinks  and 
adhesions)  remain  unchanged.  From  this  positive  fact  several 
obvious  conclusions  may  be  drawn.  The  first  is  that  kinks  and 
bands — which,  indeed,  have  been  pronounced  physiologic  by  some 
authors — are  not  necessarily  the  cause  of  intestinal  stasis,  and  that, 
consequently,  their  surgical  removal  will  not  cure  the  stasis. 
Another  conclusion  is  that  any  other  pathologic  condition  should 
disappear  after  successful  duodenal  lavage  treatment,  if  really  due 
to  intestinal  stasis;  and  if  it  does  not  disappear  after  the  supposed 
causative  factor  has  been  removed,  it  follows  that  the  etiology 
requires  correction — that  the  condition  was  not,  after  all,  due  to 
intestinal  stasis  (see  page  683) . 


BACTERIOLOGY  OF  THE  DUODENUM. 

MacNeal  and  Chace  have  made  a  careful  study  of  the  bacteria 
in  the  duodenum  with  the  aid  of  the  duodenal  tube.  They  found 
that  the  bacteria  counted  microscopically  in  the  fluids  from  the 
duodenum  varied  from  600  to  860,000  per  cubic  millimeter,  or  from 
600,000  to  860,000,000  per  cubic  centimeter.  The  bulk  of  these  were 
dead;  at  any  rate,  the  number  brought  to  development  in  culture 
was  only  a  small  fraction  of  the  number  counted.    The  number  of 


108  EXAMINATION  OF  THE  DUODENAL  CONTENTS 

bacteria  which  develop  into  colonies  in  cultures  seems  to  bear  a 
more  definite  relation  to  the  gastro-intestinal  condition.  The  fluids 
from  which  a  million  or  more  colonies  per  cubic  centimeter  developed 
were  from  patients  suffering  from  various  diseases,  most  of  them 
very  ill.  We  may  conclude,  therefore,  that  the  number  of  colonies 
developed  in  cultures  of  duodenal  fluid  is,  roughly,  an  index  of  the 
digestive  derangement.  When  these  are  numerous,  the  acidity  of 
the  gastric  juice  is  often  diminished,  or  there  is  other  evidence  of 
abnormality  in  stomach  or  duodenum. 

The  duodenal  fluid  heated  to  27°  C.  for  fifteen  minutes  and 
then  inoculated  with  spore  material  failed  to  develop  colonies. 
This  result  suggests  that  the  passage  of  bacterial  spores  through 
the  stomach  into  the  duodenum  is  not  ordinarily  a  prominent  factor 
in  the  bacterial  involvement  of  the  intestine. 

The  direct  inoculation  of  fermentation  tubes  of  glucose  broth 
and  lactose  broth  with  the  duodenal  fluid,  with  subsequent  incu- 
bation at  37°  C,  revealed  gas-producing  organisms  in  one-third  of 
the  fluids.  These  fluids  were  from  patients  suffering  from  influ- 
enzal pneumonia,  typhoid  fever,  asthenic  gastritis,  gastric  neuro- 
sis, delirium  tremens,  recurrent  ulcer  after  gastroenterostomy, 
gastric  ulcer,  and  atrophic  gastritis.  It  would  seem  that  gas  pro- 
duction in  these  cultures  takes  place  only  when  there  is  consider- 
able disturbance  of  digestion.  In  some  instances  the  gas  was 
evidently  produced  by  bacilli  and  in  other  instances  by  yeasts. 

MacNeal  and  Chace  conclude  that  the  normal  duodenal  fluid 
during  a  fast  is  almost  free  from  living  microorganisms,  although 
numerous  bacterial  cells  are  always  visible  on  microscopic  exami- 
nation. "  The  few  living  bacteria  obtained  in  cultures  from  such 
fluids  are  mostly  Gram-positive  cocci.  In  various  gastro-intes- 
tinal disturbances  the  number  of  cultivable  bacteria  in  the  duo- 
denal fluid  is  markedly  increased.  These  organisms  are  of  several 
different  varieties,  bacilli,  cocci,  yeasts  and  branching  thread 
forms  being  represented  in  different  cases.  In  cases  of  typhoid 
fever  the  Bacillus  typhosus  can  be  isolated  from  the  duodenal 
fluid.  The  bacteriologic  study  of  intestinal  juice  obtained  with 
the  duodenal  tube  is  of  value  in  cases  of  achylia  gastrica  with  diar- 
rhea, and  in  cholecystitis,  nor  is  it  without  promise  in  the  investi- 
gation of  those  obscure  diseases  which  are  sometimes  ascribed  to 
abnormal  intestinal  digestion.  Moreover,  it  may  prove  to  be  a 
valuable  procedure  in  the  early  diagnosis  of  typhoid  fever  and  in 
the  detection  of  typhoid  carriers.  Cultures  from  duodenal  contents 
removed  by  means  of  the  duodenal  tube  are  said  to  furnish  a  more 
reliable  and  simple  method  for  the  detection  of  typhoid  bacilli  than 
the  stool  examinations.  The  presence  of  pus  and  blood  always 
indicates  a  pathologic  condition.  The  microscope  reveals  epithelial 
cells,  bile-stained  cells,  and  mucus. 


DIRECT  EXAMINATION  OF  DUODENAL  CONTENTS       109 

RESULTS  OF  THE  DIRECT  EXAMINATION  OF  THE  DUODENAL 

CONTENTS. 

1.  Gall  Bladder. — The  macroscopic  appearance  of  the  bile  is  of 
great  diagnostic  import.  A  clear,  golden-yellow  bile  usually  indi- 
cates a  normal  gall  bladder.  A  turbid,  greenish  or  dark  brown 
bile,  perhaps  mixed  with  mucus,  suggests  a  diseased  state  of  either 
the  gall  bladder  or  the  liver,  or  both.  In  gall-bladder  affections  the 
bile  is  liable  to  change  in  character;  if  turbid,  this  condition  is  due 
to  admixtures  acquired  during  its  sojourn  in  the  gall  bladder.  In 
chronic  affections  of  the  liver  we  can  expect  a  fixed  appearance  of 
the  bile,  as  its  character  is  given  it  at  the  place  of  production. 

2.  Cholecystitis. — It  is  wTell  understood  that  the  diagnosis  of 
cholecystitis  or  cholelithiasis  cannot  be  made  from  the  appear- 
ance of  the  bile  alone.  The  latter,  however,  in  conjunction  with 
the  other  clinical  signs,  is  of  great  assistance  in  establishing  a  cor- 
rect diagnosis.  In  cases  of  cholecystitis  the  presence  of  innumer- 
able bile-stained  pus  cells  in  the  duodenal  contents  confirms  the 
diagnosis.  Turbid  bile  aspirated  from  the  duodenum  in  the  fasting 
condition  is  of  importance  in  the  diagnosis  of  chronic  cholecystitis. 
Clear  bile  of  a  golden  yellow  color  is  never  found  in  cases  of  chole- 
cystitis. In  some  cases  of  cholecystitis,  leukocytes  are  found  in  the 
duodenal  contents;  they  are  never  found  in  duodenal  contents 
from  normal  persons. 

3.  Bile. — Occasionally  we  obtain,  on  aspiration  of  the  duodenal 
contents,  at  first  only  a  clear  or  slightly  amber-colored  fluid,  of 
alkaline  reaction,  containing  the  pancreatic  ferments.  Usually 
after  waiting  a  short  time,  and  after  repeated  aspirations,  a  golden- 
yellow  fluid  (containing  bile)  appears.  This  has  no  diagnostic 
significance.  If,  however,  after  patient  waiting  and  aspirating, 
only  pancreatic  juice  but  no  trace  of  bile  appears,  this  fact  may  be 
of  some  importance,  particularly  in  cases  of  chronic  jaundice.  If 
bile  is  present  in  the  duodenal  contents,  complete  occlusion  of  the 
common  bile  duct  can  be  excluded.  If  the  bile  is  entirely  missing 
and  pancreatic  juice  is  present,  it  indicates  that  the  seat  of  obstruc- 
tion is  above  the  common  duct. 

4.  Obstruction  of  the  Common  Duct. — Absence  of  both  bile  and 
pancreatic  juice  suggests  a  mechanical  obstruction  of  the  common 
duct  just  above  Vater's  papilla,  thus  blocking  the  entrance  into 
the  duodenum  of  either  bile  or  pancreatic  juice.  In  these  instances 
it  is  advisable  to  ascertain  positively  that  the  tube  is  in  the 
duodenum,  by  the  milk  test  or  the  Roentgen  ray. 

5.  Bile  and  Pancreatic  Juice. — Duodenal  contents  containing 
bile  and  pancreatic  secretions  permit  gauging  the  pancreatic 
function. 

6.  Pancreatitis. — The  presence  of  the  three  ferments  in  suffi- 
cient quantity  indicates  normal  pancreatic  activity.    If  one  of  the 


110         EXAMINATION  OF  THE  DUODENAL  CONTENTS 

ferments  is  constantly  absent,  the  probability  is  that  the  patient 
has  chronic  pancreatitis.  A  tumor  of  the  pancreas  may,  however, 
exist,  notwithstanding  the  presence  of  all  three  ferments.  This 
surprising  fact  finds  its  explanation  in  the  circumstances  that  the 
tumor  has  not  invaded  all  the  pancreatic  tissue;  enough  remains 
unaffected  to  continue  the  pancreatic  function  undisturbed. 

7.  Duodenitis.— In  duodenitis,  mucus  (stringy),  Gram-positive 
motile  bacilli,  and  numerous  cocci  are  found. 

8.  Duodenal  Ulcer. — In  duodenal  ulcer,  blood  and  pus  cells  are 
frequently  found  in  the  duodenal  contents. 

9.  Typhoid  Fever. — In  typhoid  fever  the  specific  bacilli  are  fre- 
quently present  in  the  bile.  Typhoid  carriers  can  thus  be  easily 
detected. 

10.  Pernicious  Anemia. — In  pernicious  anemia,  urobilin  and  uro- 
bilinogen are  found  in  the  duodenal  contents  in  far  above  normal 
quantity.  Urobilinogen  is  increased  when  the  anemia  is  severe. 
Following  splenectomy  there  is  a  definite  decrease  in  the  amounts 
of  urobilin  and  urobilinogen  in  the  duodenal  contents — especially  a 
decrease  in  urobilinogen. 


CHAPTER   IV. 
EXAMINATION  OF  THE  FECES. 

In  the  various  chapters  treating  of  intestinal  diseases  and  cer- 
tain affections  of  the  stomach  (achylia,  subacidity)  it  is  pointed 
out  that  a  systematic  examination  of  the  feces  is  of  extreme 
importance  for  exact  diagnosis.  The  best  method  is  that  of  Adolf 
Schmidt;  indeed,  it  may  be  said  that  Schmidt  has  established  a 
functional  intestinal  diagnosis  that  is  indispensable  to  the  modern, 
up-to-date  physician  dealing  with  affections  of  the  stomach,  liver, 
gall  bladder,  and  intestine. 

The  object  of  the  functional  diagnosis  is  to  recognize  disturbances 
in  the  physiologic  action  of  the  organs,  notably  at  a  time  when 
gross  objective  signs  are  still  absent  or  when  there  are  either  indis- 
tinct subjective  sensations  or  no  symptoms  at  all.  This  object  is 
attempted  in  the  demand  made  upon  the  organ  for  the  performance 
of  a  selected  task,  and  from  the  manner  of  its  performance  conclu- 
sions are  drawn  as  to  the  capacity  of  the  organ.  In  order  to  form 
a  correct  opinion  on  any  functional  disturbance,  it  is  necessary  to 
learn,  by  accurate  and  systematic  observation,  the  normal  capacity 
of  the  organ.  By  the  modern  method  of  introducing  stomach 
tubes,  it  is  possible  to  control  to  a  nicety  the  performance  of  the 
stomach  and  to  examine  separately  its  three  principal  functions, 
motility,  secretion,  and  absorption. 

In  intestinal  pathology,  unfortunately,  we  have  as  yet  been  unable 
to  achieve  the  same  measure  of  success  in  regard  to  functional  diag- 
nosis and  the  recognition  of  normal  and  pathologic  function,  as  in 
gastric  pathology.  True,  in  the  examination  of  intestinal  function 
we  are  confronted  with  distinct  difficulties  that  are  not  encountered 
in  the  examination  of  the  stomach.  In  the  latter  organ  we  are 
dealing  with  a  comparatively  simple  condition,  there  being  only  a 
question  of  the  influence  of  two  or  three  digestive  secretions  whose 
presence  and  effect  upon  the  contents  of  a  small  and  easily  accessible 
space — the  stomach — awaits  examination.  We  are  able  to  interrupt 
the  digestive  work  of  the  stomach  at  a  definite  time  and  to  ascertain 
a  definite  phase  of  intermediate  digestion.  In  the  intestine,  how- 
ever, the  problem  is  totally  different.  Once  the  chyme  has  passed 
through  the  pylorus  and  arrived  in  the  intestine,  it  is  beyond  our 
reach,  and  the  best  we  can  do  in  the  presence  of  pathologic  condi- 
tions is  to  exert  an  influence  on  the  course  of  digestion  and  the  time 
of  retention  of  the  chyme  in  the  intestine.  We  are  unable  to  inter- 
rupt at  discretion  the  intestinal  digestive  process,  and  can  only  base 


112  EXAMINATION  OF  THE  FECES 

our  judgment  on  the  character  of  the  feces  as  the  end-product  of 
total  digestion  in  the  gastro-intestinal  canal — a  process  in  which  a 
great  many  ferments  participate,  the  absence  or  insufficient  func- 
tioning of  which  cannot  always  be  determined  with  certainty. 

Nothnagel  was  the  first  to  evolve  a  valuable  method  of  fecal 
examination,  in  the  'eighties.  In  later  years  his  labors  fell  into 
neglect,  and  there  were  only  sporadic  contributions  to  the  litera- 
ture of  fecal  examination.  The  interest  in  these  examinations  had 
almost  completely  died  out  when  Adolf  Schmidt,  as  mentioned 
above,  and  his  collaborator  Strasburger,  reclaimed  coprology  from 
oblivion,  placing  it  on  a  theoretically  and  practically  assured  basis 
and  rendering  it  accessible  to  wider  circles. 

The  method  of  Schmidt  and  Strasburger  consists  in  demanding 
from  the  intestine  the  performance  of  a  certain  task,  and  observing 
the  manner  in  which  it  is  performed  on  the  principle  of  the  test 
breakfast  and  test  meal  on  which  the  function  of  the  stomach  is 
determined.  The  demand  made  upon  the  intestine  is  that  it  deal 
with  a  certain  uniformly  constituted  diet,  the  so-called  test  diet. 
The  question  of  whether  and  how  the  intestine  digests  and  assimi- 
lates this  test  diet  is  determined  by  examination  of  the  feces,  so 
that  the  procedure  of  functional  examination  is  divided  into  two 
parts:  (1)  administration  of  the  test  diet,  and  (2)  examination  of 
the  stool  resulting  from  the  test  diet. 


THE  TEST  DIET  AND  ITS  ADMINISTRATION. 

The  demands  to  be  made  upon  a  suitable  test  diet  are  many.  It 
should  be  made  up  in  such  a  way  as  to  be  equally  acceptable  to 
healthy  and  to  intestinally  diseased  individuals.  It  should  be  almost, 
but  not  entirely;  free  from  indigestible  matter,  so  that  the  irritation 
normally  supplied  by  the  intestinal  contents  may  not  be  entirely 
absent.  Furthermore,  it  should  satisfy  the  minimum  caloric  require- 
ments in  physical  rest;  it  should  contain  a  suitable  proportion  of 
protein,  fat,  and  carbohydrates;  it  should  be  easily  procurable  and 
easy  to  prepare.  In  Schmidt's  original  test  diet,  importance  was 
attached  to  the  exact  measurement  of  all  the  articles  of  nutrition 
contained.     It  was  as  follows: 

Morning.  Milk  0.5  liter,  or,  if  milk  is  not  well  tolerated,  cocoa 
0.5  liter,  prepared  with  20  grams  of  powdered  cocoa,  10  grams  of 
sugar,  400  Cc.  of  water,  and  100  Cc.  of  milk;  together  with  50 
grams  of  biscuits. 

Forenoon.  One-half  liter  of  oatmeal  gruel  (oatmeal  40  grams, 
butter  10  grams,  milk  200  Cc,  water  300  Cc,  one  egg  and  a  little 
salt;  strained). 

Mid-day.  Chopped  beef  (125  grams  gross  weight)  slightly 
roasted  with  20  grams  of  butter,  care  being  taken  that  the  inside 


THE  TEST  DIET  AND  ITS  ADMINISTRATION  113 

remains  rare.  Mashed  potatoes,  250  grams  (potatoes  190  grams, 
milk  100  Cc,  butter  10  grams,  and  a  little  salt). 

Afternoon.   Like  the  morning  diet. 

Evening.    Like  the  forenoon  diet. 

This  diet  contains:  milk  1.5  liters,  two  eggs,  100  grams  of  biscuits, 
oatmeal  S00  grams,  butter  50  grams,  beef  125  grams,  potatoes  190 
grains,  having  the  following  composition : 


Protein. 

Fat. 

Carbohydrates 

Milk,  1.5  liters  . 

.      .     45.0 

53.2 

67.6 

10.9 

0.5 

Biscuits,  100  grams 

.     .       8.55 

0.98 

75.1 

Oatmeal,  80  grams 

.      .       1.76 

1.2 

8.2 

Butter,  50  grams    . 

.      .       0.37 

42.2 

Beef,  125  grams 

.      .     26.1 

1.96 

Potatoes,  190  grams 

.      .       3.95 

0.28 

39.9 

97.03  110.72  191.3 

Calculating  the  protein  at  4  calories,  the  fat  at  9,  the  carbohy- 
drates at  4,  this  test  diet  would  yield  2131.8  gross  calories.  Accord- 
ing to  Lohrisch,  the  direct  combustion  of  this  test  diet  in  the  calor- 
imeter yields  2146.3  calories,  which  corresponds  closely  enough. 
Also  according  to  Lohrisch,  the  cellulose  content  of  one  day's  test 
diet  amounts  to  0.8916  gram.  However,  in  the  course  of  years 
it  has  been  foimd  that,  for  practical  purposes,  the  precise  quantita- 
tive determination  of  the  various  nutritive  ingredients  is  not  at  all 
necessary.  It  should  simply  be  borne  in  mind  that  the  test  diet 
should  be  composed  of  milk  in  not  too  restricted  quantities  (|  to 
1^  liters);  white  bread  or  crackers,  about  100  grams;  potato 
puree,  100  to  250  grams;  chopped  beef,  120  grams.  But  many 
additions  or  omissions  may  be  resorted  to,  to  suit  the  taste 
and  requirements  of  the  patient.  The  accurately  measured  diet 
is  now  used  only  for  exact  clinical  examination  and  quantitative 
analyses.  For  practical  purposes  Schmidt  now  lays  down  the 
following  changed  and  amplified  form  of  his  test  diet: 

Morning.  Milk  \  liter,  or  tea  or  cocoa  with  much  milk  if  accept- 
able; one  roll  and  one  soft-boiled  egg. 

Breakfast.  Oatmeal  gruel,  strained,  one  plate,  with  a  little  salt 
or  sugar  if  desired;  farinaceous  soup  or  porridge  may  be  substituted. 

Mid-day.  Lean  beef,  well  chopped  and  slightly  roasted  (inside 
rare),  with  potato  puree,  finely  strained,  the  quantity  not  to  be  too 
small. 

Afternoon.    Like  the  morning  diet,  but  without  the  egg. 

Evening.  Milk  §  liter,  or  a  plate  of  soup  (as  for  breakfast),  one 
roll  with  butter,  and  one  or  two  soft-boiled  eggs  or  scrambled  eggs. 
A  little  wine  is  also  permitted,  also  the  addition  of  weak  coffee  or 
tea,  bouillon,  and  chopped  cold  roast  veal. 

This  is  an  absolutely  bland  and  non-irritating  diet,  which  as  far 
as  possible  meets  the  requirements  and  the  personal  taste  of  the 
8 


114  EXAMINATION  OF  THE  FECES 

patient,  with  no  difficulties  whatever  in  the  way  of  procuring  or 
preparation,  as  it  includes  only  the  simplest  and  always  obtainable 
articles  of  food. 

In  spite  of  many  objections  this  test  diet  has  met  with  general 
approval.  The  objections  were  principally  to  the  effect  that  the 
diet  list  was  not  the  only  possible  one — which  of  course  is  correct. 
It  is  quite  possible  to  compose  a  different  test  diet  which  would 
meet  the  demands  laid  down.  But  the  value  of  the  Schmidt  for- 
mula lies  in  the  fact  that  upon  it  as  a  basis,  and  through  the  labors 
of  Schmidt,  Strasburger,  and  their  co-workers,  our  entire  system  of 
modern  coprology  and  functional  intestinal  diagnosis  has  been 
constructed.  All  the  numerous  analyses  and  stool  examinations 
which  have  furnished  material  for  establishing  systematic  intes- 
tinal diagnosis  have  been  made  with  this  test  diet.  If  at  the  present 
time  we  are  able  to  speak  of  "normal  feces,"  we  are  indebted  for 
this  achievement  to  the  application  of  just  this  test  diet.  As  soon, 
moreover,  as  we  make  quantitative  or  qualitative  changes  in  the 
material  points  of  this  test  diet,  we  rob  the  fecal  examination  of 
its  firm  and  assured  foundation  and  destroy  the  object  of  compari- 
son— the  normal  feces — of  which  we  must  always  avail  ourselves  in 
judging  pathologic  conditions. 

As  a  rule,  this  test  diet  is  well  tolerated.  Milk,  possibly,  might 
occasionally  give  rise  to  diarrhea.  In  such  cases  the  milk  is  boiled 
together  with  cocoa  or  replaced  entirely  by  the  latter. 

For  purposes  of  examination  the  test  diet  is  taken  for  two  or 
three  succeeding  days,  or  at  all  events  for  a  sufficient  time  to  make 
sure  of  the  fact  that  the  stool  is  derived  from  it. 

EXAMINATION  OF  THE  TEST-DIET  STOOL. 

The  test-diet  stool  is  collected  in  a  chamber,  transferred  to  a  glass 
or  tin  vessel  specially  reserved  for  this  purpose,  and  sent  to  the  physi- 
cian. If  the  feces  are  hard  or  thick,  a  wooden  spatula  may  be  used 
for  transferring  them  from  the  chamber;  feces  of  fluid  consistency 
may  be  poured  into  the  receptacle  for  transportation. 

Having  thus  obtained  the  test  stool,  the  next  step  is  its  examina- 
tion. This  should  be  made  macroscopically,  microscopically,  and 
chemically. 

A.  Macroscopic  Examination. — The  feces  should  always  be  examined 
as  soon  as  possible  after  defecation.  They  should  first  be  inspected 
and  examined  as  to  color,  consistency,  odor,  and  gross  admixtures  of 
mucus,  blood,  pus,  and  helminths. 

The  next  step  in  the  macroscopic  examination  is  the  trituration 
of  the  feces.  (Plate  VI.)  This  is  done  in  the  following  manner: 
The  entire  quantity  is  thoroughly  mixed,  with  a  wooden  spatula 
(Fig.  14,  a),  so  that  it  becomes  a  homogeneous  mass  and  it  is  cer- 
tain that  a  sample  taken  from  it  represents  the  mixture.     Of  these 


PLATE    VI 


Normal  Test-diet  Feces  (Macroscopic). 


Pathologic  Test-diet  Feces  (Macroscopic) 

a,  musele;  6,  potato;  c,  connective  tissue;   d,  fat;  e,  mucus. 


EXAMINATION  OF  THE  TEST-DIET  STOOL  1  15 

stirred  feces  a  small  portion,  the  size  of  a  walnut,  is  carefully  trit- 
urated in  a  mortar  (Fig.  14,  b),  with  gradual  addition  of  water  until 
the  mass  is  of  the  consistency  of  soup.  The  trituration  should  be 
done  so  carefully  that  no  coherent  non-triturated  particles  will  be 
visible  to  the  eye.  These  feces,  triturated  to  the  finest  possible 
consistency,  are  poured  out  and  spread  upon  a  black  plate  (Fig. 
14,  d),  where  it  will  be  possible  to  observe  with  the  greatest  accuracy 
and  distinctness  whether  any  parts  of  the  test  diet,  and  which, 
have  been  evacuated  in  a  macroscopically  visible  form — i.  e.,  have 
not  been  digested  and  assimilated.  The  macroscopic  examina- 
tion, therefore,  includes  a  search  for  connective  tissue  of  the  meat 
(Plate  VI,  Fig.  2,  c),  particles  of  muscle  (Plate  VI,  Fig.  2,  a),  potato 
remnants  (Plate  VI,  Fig.  2,  b),  fat  (Plate  VI,  Fig.  2,  d),  and  cellulose 
residue.  Furthermore,  in  this  examination  it  will  be  possible  to 
recognize  constituents  which  do  not  originate  from  the  test  diet, 
but  from  the  intestine  itself,  as  for  instance  the  important  matter 
of  mucus  (Plate  VI,  Fig.  2,  e),  small  pus  flakes,  and  large  crystals  of 
ammonio-magnesiirm  phosphate. 


Fig.  14. — Necessary  apparatus  for  making  analysis  of  feces:    a,  -wooden  spatula; 
b,  mortar;  c,  watch  crystals;  d,  black  plate;  e,  fermentation  tubes. 

B.  Microscopic  Examination. — The  microscopic  examination  serves 
to  supplement  [the  macroscopic,  and  requires  three  different  pro- 
cedures: 

1.  Inspection  of  a  small  particle  of  the  untriturated  feces,  spread 
in  a  thin  layer  under  the  cover-glass:  examination  as  to  the  presence 
of  muscle  particles,  fat  in  its  various  forms,  potato  cells,  cellulose 
remnants,  cocoa  remnants,  mucus,  pus,  and  parasite  eggs. 

2.  A  small  particle  of  feces  is  thoroughly  triturated  on  a  slide 
with  a  few  drops  of  a  30-per-cent.  acetic  acid  solution,  by  means 
of  a  needle;  heated  for  a  moment  over  a  flame  to  the  boiling-point, 
and  inspected  under  the  cover-glass.  By  this  process  all  the  fat 
remnants  are  temporarily  melted,  the  entire  quantity  of  fat  being 
shown  in  the  wTarm  preparation  in  the  shape  of  liquid  globules 
of  fatty  acid,  spread  over  the  entire  surface.  As  the  preparation 
cools,  the  drops  coagulate  into  untransparent  masses  of  fatty  acid. 
From  this  preparation  it  is  possible  to  approximately  estimate  the 
fat  content  of  the  feces. 

3.  A  small  particle  of  the  feces  is  carefully  triturated  on  the  slide 
with  a  droplet  of  a  strong  compound  solution  of  iodin  (iodin  1, 
potassium  iodid  2,  distilled  water  50),  and  inspected  under  a  strong 


116  EXAMINATION  OF  THE  FECES 

light  under  the  cover-glass.  By  this  means  any  remnants  of  starch, 
either  enveloped  in  cellulose  or  free,  which  stain  blue  with  iodin, 
will  be  recognized.  At  the  same  time  it  is  possible  to  observe  any 
blue-stained  iodin  fungi  and  yellow-stained  yeast  cells. 

C.  Chemical  Examination.  1.  Reaction  Test. — The  simplest  method 
of  testing  the  reaction  consists  in  bringing  a  strip  of  red  and  a  strip 
of  blue  litmus  paper,  soaked  in  water,  into  contact  with  the  feces, 
and  observing  the  change  of  color  on  the  outer  side  of  the  paper. 
Schmidt  recommends  Azolitmin  paper,  which  is  prepared  from  the 
pure  litmus  coloring  substance. 

2.  Schmidt's  Sublimate  Test. — The  sublimate  test  serves  to  dis- 
cover whether  the  feces  contain  the  normal  fecal  pigment,  hydro- 
bilirubin,  or  pathologically  unchanged  biliary  pigment  (bilirubin). 
The  test  is  based  upon  the  fact  that  hydrobilirubin  stains  intensely 
tile-red  owing  to  the  formation  of  mercurial  chlorid  of  hydrobili- 
rubin, while  bilirubin  with  sublimate  stains  green  owing  to  the 
oxidation  of  the  bilirubin,  changing  it  to  biliverdin.  For  this  pur- 
pose it  is  necessary  to  triturate  in  a  mortar  (Fig.  14,  b)  a  walnut- 
sized  piece  of  feces  to  a  thin  consistency,  adding  a  generous  portion 
of  concentrated  aqueous  sublimate  solution  (corrosive  sublimate 
25,  sodium  chlorid  25,  distilled  water  500),  which  is  thoroughly 
mixed  with  the  feces.  The  tile-red  stain  of  hydrobilirubin  will  then 
rapidly  occur  with  fresh  feces  (Plate  VII,  a).  Feces  which  have  been 
standing  for  some  time  produce  a  reddish-brown  to  a  dirty  brown 
color.  The  mixture  should  be  allowed  to  stand  for  twenty-four 
horns,  when  any  unchanged  biliary  pigment  that  may  be  present 
will  be  found  to  be  stained  green  (Plate  VII,  6).  In  that  case,  either 
the  entire  quantity  of  feces  is  stained  green  or  only  a  few  macro- 
scopic or  microscopic  green  particles  may  be  visible. 

3.  Schmidt's  Incubator  Test.— The  incubator  test  is  instituted 
to  show  whether  the  feces  incline  to  carbohydrate  fermentation  or 
to  protein  putrefaction,  or  whether  they  are  negative.  For  this 
purpose  Strasburger's  fermentation  tube  (Fig.  15)  is  employed. 
This  fermentation  tube  has  a  bottom  vessel  (a),  into  which  5 
grams  of  formed  feces  are  put  with  a  wooden  spatula  and  well 
stirred  with  water.  If  the  stool  is  hard,  a  smaller  quantity  is  taken, 
a  larger  one  if  it  is  liquid.  The  bottom  vessel  is  closed  with  a  per- 
forated rubber  cork,  which  is  then  connected  with  another  and 
doubly  perforated  rubber  cork  carrying  a  small  tube  (b)  filled  with 
tap  water,  and  connected  by  a  piece  of  U-glass  tubing  with  another 
small  tube  (c)  which  has  an  aperture  at  its  upper  end.  The  appa- 
ratus is  kept  in  the  incubator  for  twenty-four  hours  at  a  tempera- 
ture of  37°  C.  Should  gas  develop,  it  will  enter  from  the  bottom 
vessel  (a)  into  the  tube  b,  displacing  the  water  into  the  empty 
tube  (c).  Carbohydrate  fermentation  is  assumed  to  exist  if  after 
twenty-four  hours  the  outer  tube  (c)  is  about  half-filled  with  water; 
if  the  reaction  of  the  feces  has  become  distinctly  acid;  if  the  feces 


PLATE    VII 


Sublimate  Test. 

a,  normal  feces;  6,  pathologic  feces. 


EXAMINATION  OF  THE  TEST-DIET  STOOL 


11' 


~e 


in  the  bottom  vessel,  when  it  is  opened,  have  an  odor  of  butyric 
acid  and  their  color  has  turned  light  yellow.  Albuminous  putre- 
faction has  taken  place  if  the  reaction  of  the  feces  has  become 
strongly  alkaline,  there  is  a  distinct  odor  of  putrefaction,  the  feces 
have  assumed  a  dark  color,  and  there  is  but  slight  development 
of  gas.  Baurmeister  has  modified  the  fermentation  tube  so  that  it 
is  easily  manipulated  and  more  durable.  The  modification  consists 
of  three  ordinary  wide-mouthed  bottles  connected  by  glass  tubing 
through  perforated  rubber  stoppers  (Fig.  14,  e).  The  ground  feces 
are  placed  in  the  first  bottle,  the  second  bottle 
is  filled  with  water,  and  the  third  bottle  re- 
mains empty.  In  the  presence  of  fermenta- 
tion or  putrefaction,  the  generated  gas  forces 
the  water  with  some  of  the  feces  into  the  third 
bottle.  The  degree  of  decomposition  is  deter- 
mined by  the  quantity  of  fluid  in  the  third 
bottle.  YYhen  the  test-diet  feces  are  normal 
the  second  and  third  bottles  remain  the  same 
as  when  first  placed  in  the  incubator  (Plate 
VIII,  a).  In  the  presence  of  fermentation,  some 
of  the  yellow  feces  are  forced  into  the  two 
other  bottles  (Plate  VIII,  b).  The  feces  are 
usually  darker  in  the  presence  of  putrefaction 
(Plate  VIII,  c). 

4.  Examination  for  Dissolved  Protein. — For 
this  purpose  the  following  procedure  is  insti- 
tuted. The  feces  (daily  quantity)  are  well 
triturated,  water  being  added  slowly,  and  further 
diluted  with  water  until  a  rather  liquid  consist- 
ency (about  500  Cc,  or  one  pint)  is  obtained. 
This  fluid  is  allowed  to  stand  for  a  few  hours 
and  is  then  filtered  through  a  double  filter. 
The  turbid  filtrate  is  then  passed  for  clarifica- 
tion through  a  silicated  filter,  which  usually 
yields  a  clear  filtrate.  If  it  be  desired  to 
test  the  clear  filtrate  for  dissolved  protein 
(peptone,  albumose),  it  will  be  necessary  to  first  remove  the  nu- 
cleoproteins  which  are  present  in  every  fecal  extract.  This  is 
effected  by  the  careful  addition,  in  droplets,  of  a  30-per-cent. 
acetic  acid  solution  to  the  liquid,  in  a  test  tube.  The  precipitated 
nucleoproteins  cause  a  turbidity  of  the  previously  clear  filtrate, 
which  must  now  be  passed  through  a  double  la\er  of  filters.  If 
the  resulting  filtrate  is  limpid  and  free  from  nucleoproteins,  a  few 
more  drops  of  a  3-  to  5-per-cent.  solution  of  acetic  acid  should  be 
added  in  order  to  make  doubly  sure  that  all  of  the  nucleoproteins 
have  been  precipitated,  after  which  the  usual  albiimin  test  (boiling 
with  acetic  acid,  the  ring  test  with  nitric  acid,  or  the  ferrocyanide-of- 


Fig.  15. — Strasburger's 
fermentation  tubes. 


118  EXAMINATION  OF  THE  FECES 

potassium  test)  should  be  instituted.  Should  the  filtrate,  turbid 
from  the  precipitated  nucleoproteins,  remain  so  after  the  second 
filtration,  it  should  once  more  be  filtered  through  a  silicated  filter, 
which  will  clarify  it  and  make  it  ready  for  examination  for  dissolved 
protein. 

Quantitatively,  the  protein  in  the  nucleoprotein-free  fecal  extract 
can  be  determined  by  Esbach's  reagent,  or  Tsuchiya's  1-per-cent. 
solution  of  alcoholic  phosphorous  acid  (Wolfram — phosphorous  acid 
1,  hydrochloric  acid  5,  96-per-cent.  alcohol  100).  Tsuchiya  has 
proposed  special  tubes,  suitable  for  the  Wolfram  phosphorous  acid 
test. 

In  this  way  every  test-diet  stool  should  be  examined,  particularly 
by  the  beginner.  The  entire  examination  as  above  described  will 
not  occupy  more  than  a  quarter  of  an  hour  at  the  most.  As  expe- 
rience increases,  the  incubation  test  and  the  demonstration  of 
dissolved  protein  may  in  many  cases  be  entirely  dispensed  with, 
the  macroscopic  and  if  necessary  the  microscopic  examinations 
allowing  a  sufficient  survey  of  the  functional  condition  of  the 
intestine.  The  most  important  part  of  Schmidt's  stool  examina- 
tion certainly  is  the  macroscopic  examination,  which  alone  is  usually 
sufficient  for  the  experienced  practitioner.  Aside  from  Schmidt's 
technic  of  examination,  the  demonstration  of  blood  and  certain 
ferments  in  the  feces  is  of  importance.  For  these  examinations  a 
special  test  diet  is  not  required. 

Bacterial  Preparations. — In  order  to  separate  the  microorganisms 
from  the  other  constituents  of  the  feces,  the  following  method  has 
been  evolved  by  Strasburger:  A  small  quantity  of  feces,  about  the 
size  of  half  a  pea,  is  triturated  with  a  few  cubic  centimeters  of  water 
and  the  mixture  centrifugalized.  The  turbid  liquid,  containing  bac- 
teria, is  poured  off  the  sediment;  one  part  is  then  diluted  with 
two  parts  of  96-per-cent.  alcohol  and  this  mixture  is  centrifugalized. 
Of  the  resulting  bacterial  sediment  a  small  quantity  is  placed  upon 
the  slide,  the  liquid  is  allowed  to  run  off,  and  the  bacteria  are  dis- 
tributed in  a  uniform  stratum  upon  the  slide  by  covering  the  latter 
with  a  second  slide,  which  is  then  drawn  off.  The  result  will  be 
a  very  fine,  even  stratum,  to  be  fixed  over  a  flame.  Staining  agents 
are:  Loeffler's  methylene  blue,  a  10-per-cent.  aqueous  solution  of 
carbolated  fuchsin,  Ziehl's  carbolated  fuchsin  for  the  demonstra- 
tion of  tubercle  bacilli,  and  a  strong  Lugol  solution  for  staining 
granulose  fungi. 

THE  NORMAL  TEST-DIET  STOOL. 

It  has  already  been  pointed  out  how  important  it  is  for  diagnostic 
purposes  to  know,  and  always  to  remember,  the  picture  of  the  nor- 
mal test-diet  stool  (Plate  VI,  Fig.  1)  occurring  in  cases  of  intact 
gastric  and  intestinal  function,  since  without  such  knowledge  of  the 


PLATE    VIII 


^ 


b  — 


Test-diet  Feces. 

a,   normal;   h,   fermentation;   c,   putrefaction. 


SIGNIFICANCE  OF  PATHOLOGIC  STOOLS  119 

normal  feces  it  is  impossible  to  form  a  correct  opinion  of  pathologic 
stools. 

Normal  test-diet  feces  are  either  massy  or  of  salve-like  consis- 
tency, almost  odorless,  light  yellow  in  milk  diet,  dark  brownish  on 
cocoa  diet,  and  do  not  exhibit  any  striking  admixtures  upon  super- 
ficial inspection.  Macroscopic  examination  will  possibly  reveal 
among  the  food  remnants  a  few  bits  of  coimective  tissue  or  sinews 
and  isolated  red-brown  cellulose  remnants,  of  pinhead  size,  resulting 
from  oatmeal  gruel.  Otherwise  the  normal  stool  consists  of  a 
homogeneous  mass  of  detritus  in  which  other  food  remnants  cannot 
be  macroseopically  discovered. 

Microscopically  (see  page  115),  Preparation  1  reveals  isolated  yel- 
lowish muscle-fiber  fragments,  rounded  at  the  edges  and  occasionally 
still  transversely  striated  to  a  small  extent;  fat  in  the  shape  of 
disseminated  large  or  small  so-called  yellow  calcium  salts  (fatty 
acid  calcium)  in  irregular  yellow  particles,  or  colorless  fatty  soaps 
in  straight  or  roundish  forms;  isolated  empty  potato  cells;  a  few 
cellulose  remnants;  small  brownish  cocoa  remnants. 

In  Preparation  2  the  field  of  vision  here  and  there  presents  larger 
or  smaller  deposits  of  fatty  acid. 

In  Preparation  3  no  blue  coloration  can  be  detected  at  all. 

On  chemical  examination  the  normal  stool  exhibits  either  a  very 
weak  acid  or  an  equally  weak  alkaline  reaction.  In  the  incubator 
its  behavior  is  indifferent.  The  sublimate  test  (Plate  VII,  a)  yields 
an  intense  tile -red  coloration  (hydrobilirubm).  No  dissolved  protein 
is  demonstrable. 

PATHOLOGIC    STOOLS    AND    THEIR    SIGNIFICANCE    IN    THE 
DIAGNOSIS  OF    GASTRIC  AND  INTESTINAL   AFFECTIONS. 

The  object  of  the  test  diet  is  examination  of  the  intestinal  func- 
tion. The  intention,  therefore,  is  to  detect,  as  far  as  may  be  pos- 
sible, the  more  minute  disturbances  of  absorption,  motility,  and 
secretion,  as  well  as  the  lighter  inflammatory  conditions  of  the  intes- 
tine and  the  lighter  and  less  grave  chronic  catarrhs  in  organic  affec- 
tions of  the  intestine.  Thus  it  is  the  small  intestine  which  holds  our 
special  interest.  It  is  clear  that  there  is  no  need  for  a  test  diet  to 
demonstrate  grave  organic  affections  of  the  intestine,  such  as  carci- 
noma, stenoses,  hemorrhages,  grave  catarrhs,  ulcers,  etc. 

A.  Pathologic  Food  Remnants. — Connective  Tissue. — If  connective- 
tissue  remnants  appear  in  the  feces,  there  is  a  disturbance  of 
gastric  digestion  (Plate  VI,  Fig.  2,  c).  This  is  fully  explained  in 
Chapter  XXXVIII  on  Chronic  Diarrhea.  Only  the  gastric  juice 
is  capable  of  digesting  raw  connective  tissue.  In  the  majority  of 
cases  there  is  a  question  of  achylia  gastrica  or  subacidity,  both  as 
an  independent  disease  and  as  a  sequel  to  catarrhs  and  carcinoma. 
In  hydrochloric  acid  insufficiency,  accelerated   motility  probably 


120  EXAMINATION  OF  THE  FECES 

also  plays  a  role,  because  even  in  the  normal  chemism  of  the  stom- 
ach connective  tissue  may  appear  in  the  feces  when  there  is  accel- 
erated gastric  motility.  Even  in  hyperacidity  there  are  occasionally 
remnants  of  connective  tissue,  and  in  these  cases,  provided  the 
motility  is  normal  or  retarded,  it  will  be  necessary  to  think  of 
insufficient  secretion  of  pepsin,  which  may  exist  in  spite  of  increased 
secretion  of  hydrochloric  acid.  It  is  the  presence  of  connective 
tissue  in  the  stool  which  in  many  cases  renders  a  correct  diagnosis 
possible,  because  even  when  intestinal  catarrh  and  disturbed 
absorption  coexist  the  connective-tissue  remnants  point  to  the 
stomach  as  the  origin  of  these  intestinal  affections. 

Muscle  Remnants. — If  muscle  remnants  can  be  macroscopically 
detected  in  the  feces,  there  is  a  digestive  disturbance  of  the  small 
intestine.  The  stomach  is  involved  in  only  a  minor  degree  in  the 
digestion  of  meat.  Muscle  remnants  can  be  recognized  in  finely 
triturated  feces  either  as  very  small  or  as  large  red-brown  lumps 
(Plate  VI,  Fig.  2,  a).  They  can  be  smoothed  out  under  pressure 
of  the  cover-glass  and  distributed  with  the  needle.  If  there  are 
macroscopic  muscle  remnants  of  tins  kind,  the  fact  points  to 
insufficiency  of  pancreatic  secretion,  or  absence  of  activating  entero- 
kinase  in  the  secretion  of  the  small  intestine,  or  exaggerated  peri- 
stalsis to  such  an  extent  that  there  is  no  time  for  digestion;  or 
else  a  primary  absorptive  disturbance  of  the  small  intestine  has  led 
to  decomposition  and  secondarily  to  diarrhea.  It  follows,  there- 
fore, that  the  appearance  of  muscle  fragments  alone  is  not  suffi- 
cient to  establish  the  disturbance  of  a  definite  intestinal  function; 
all  that  can  be  said  is  that  the  disturbance  must  be  looked  for  in 
the  small  intestine. 

Macroscopic  muscle  remnants  may  under  certain  circumstances 
be  absent  while  microscopically  the  feces  will  reveal  exceedingly 
numerous  and  poorly  digested  muscle  remnants.  These  findings 
have  the  same  value  as  macroscopic  muscle  remnants,  but  should 
be  weighed  with  even  greater  care. 

If  remnants  of  connective  tissue  and  muscles  are  found  in  close 
proximity  or  even  in  contact  with  each  other,  the  circumstance  is 
proof  of  disturbed  gastric  and  intestinal  fimction. 

Fat — Abnormal  fat  residues  in  the  feces  can  be  macroscopically 
recognized  from  their  glistening,  clay-like  appearance  (Plate  VI, 
Fig.  2,  d).  Again,  when  the  feces  are  finely  triturated  with  water, 
there  is  frequently  a  fatty  membrane  visible  at  the  surface.  The 
presence  of  much  fat  imparts  to  the  feces  the  well-known  clay  color. 
In  the  microscopic  acetic  acid  preparation  the  presence  of  increased 
fat  is  assumed  if  the  droplets  of  fatty  acid  in  the  field  are  materially 
increased  in  comparison  with  those  of  normal  feces. 

Pathologically,  fat  occurs  in  the  shape  of  fatty  acid  needles  and 
neutral  fat.  The  fatty  acid  needles  are  long,  thin,  finely  curved, 
and  oftentimes  arranged  in  rays.     Soap  needles,  on  the  other  hand, 


SIGNIFICANCE  OF  PATHOLOGIC  STOOLS  121 

are  smaller]  thicker,  and  more  compact.  Neutral  fat  occurs  in  the 
shape  of  light-colored  or  yellowish  drops  and  scales. 

The  occurrence  of  fatty  stools  is  commonly  associated  with  insuf- 
ficiency of  biliary  secretion  or  impeded  biliary  flow  into  the  intes- 
tine (icterus).  In  disturbed  pancreatic  secretion,  pronounced  fatty 
stools  likewise  occur;  in  tins  case  the  fat  is  present  mostly  as  neu- 
tral fat.  Furthermore,  fatty  stools  will  occur  in  disturbed  intestinal 
digestion,  especially  in  grave  orgame  affections  such  as  tuberculosis, 
amyloid  degeneration,  or  tabes  mesenterica. 

Carbohydrates. — Potato  Remnants. — These  are  macroscopic-ally 
visible  in  finely  triturated  feces  as  isolated  and  usually  very  numer- 
ous potato  cells  or  as  small,  sago-like,  coherent  potato  cells  (Plate 
VI,  Fig.  2,  b)  which  can  microscopically  be  recognized  as  potato 
from  their  size  and  shape  (large,  roundish).  From  the  microscopic 
examination  the  condition  is  considered  pathologic  if  there  are 
numerous  potato  cells  in  the  field  of  vision.  The  pathologic  potato 
remnants  usually  contain  starch,  which  is  microscopically  demon- 
strable in  the  iodin  preparation. 

Starch. — If  there  is  a  disturbance  in  the  carbohydrate  digestion, 
free  starch  granules  are  usually  to  be  found,  either  whole  or  frag- 
mented, and  visible  in  the  iodin  preparation. 

Insufficient  starch  digestion  is  chargeable  to  the  small  intestine, 
and  is  probably  caused  by  a  disturbance  of  the  secretory  function 
of  that  section  of  the  intestinal  tract. 

B.  Pathologic  Products  of  the  Intestinal  Wall. — Mucus. — The 
presence  of  mucus  in  the  feces  is  always  a  sign  of  an  inflammatory 
condition  of  the  intestinal  mucosa,  with  the  exception  of  that  vis- 
cous brownish  mucus  which  often  adheres  to  the  feces  and  originates 
in  the  rectum,  and  of  the  mucus  that  is  often  profusely  evacuated 
in  enteritis  membranacea.  As  a  rule  the  mucus  can  be  made 
plainly  visible  in  the  finely  water-triturated  feces  poured  out  on  a 
black  plate;  it  appears  in  large  or  small  flakes  which  are  trans- 
parent upon  the  black  ground,  capable  of  being  moved  to  and  fro 
with  the  needle,  and  separated  only  with  difficulty  (Plate  VI,  Fig. 
2,  e).  Oftentimes,  however,  it  is  not  an  easy  matter  to  determine 
whether  the  mucus  originates  in  the  small  or  in  the  large  intestine. 
Generally  speaking,  mucus  from  the  large  intestine  is  large-flaked, 
often  of  a  whitish  turbidity,  and  usually  contains  numerous  well- 
preserved  intestinal  epithelial  cells.  Mucus  originating  from  the  small 
intestine,  on  the  other  hand,  contains  no  epithelia,  but  at  the  most 
a  few  undigested  cell  nuclei  and  very  many  bacteria.  If  the  mucus 
has  a  biliary  tint  or  stains  green  under  the  sublimate  test,  the 
probability  is  that  it  is  from  the  small  intestine.  Microscopically 
it  is  often  possible  to  find  minute  bilirubin  crystals  in  the  small 
mucous  flakes  from  the  small  intestine. 

Soluble  Protein. — The  small  mucous  flakes  of  the  small  intestine 
are  often  dissolved  before  they  leave  the  intestine  with  the  feces, 


122  EXAMINATION  OF  THE  FECES 

so  that  a  search  for  them  in  the  feces  is  fruitless.  In  that  case  the 
chemical  examination  of  the  feces  for  protein  offers  an  equivalent 
substitute.  Very  frequently  a  pronounced  decomposition  of  pro- 
tein (incubator  test),  or  dissolved  protein,  is  found  in  cases  of 
intestinal  inflammation  (Plate  VIII,  c).  This  finding  is  by  no  means 
a  result  of  decomposition  of  undigested  remnants  of  food,  but 
indicates  a  putrefaction  of  the  pathologic  albuminous  products  of 
elimination  on  the  part  of  the  inflamed  mucosa  itself.  A  product 
of  this  kind  is  mucous,  but  more  particularly  serous,  thrown  into 
the  intestinal  lumen  by  transudation  in  inflammatory  conditions. 
Thus,  the  demonstration  of  the  putrefactive  character  of  a  stool 
is  equivalent  to  a  demonstration  of  mucus.  Mucus,  putrefaction, 
and  the  presence  of  soluble  protein  are  the  characteristics  of  the 
stool  in  catarrh  of  the  small  intestine;  and  on  the  ground  of  these 
findings  we  are  often  in  a  position  to  make  a  diagnosis  of  catarrh 
of  the  small  intestine  at  a  time  when  there  is  nothing  but  a  slight 
inflammation,  and  no  pronounced  symptoms  are  apparent. 

Suppuration. — Suppuration  occurs  in  grave  catarrh  and  especially 
in  ulceration  of  the  intestinal  canal.  It  is  visible  in  the  finely 
triturated  stool  on  a  black  ground  in  the  shape  of  small,  lentil- 
shaped,  yellowish -gray  flakes,  which  microscopically  turn  out  to 
consist  of  purulent  matter. 

C.  Unchanged  Biliary  Pigment  (Bilirubin)  .—It  is  a  pathologic  sign 
if,  with  the  sublimate  test,  the  entire  quantity  of  feces  under  exam- 
ination or  only  a  microscopic  part  of  it  stains  green  (Plate  VII,  b). 
It  is  proof  that  the  bilirubin,  after  having  entered  the  cecum,  has 
not  been  normally  reduced  to  hydrobilirubin.  This  defect  may 
occur  when  the  motility  of  the  intestine  is  not  particularly  exagger- 
ated or  when,  for  some  reason,  the  normal  process  of  reduction  is 
absent.  As  a  rule  the  green  coloration  of  the  feces  is  a  sign  of 
pathologic  involvement  of  the  small  intestine. 

If  a  fecal  specimen,  when  subjected  to  the  sublimate  test,  does 
not  stain  at  all,  the  fact  proves  the  total  exclusion  of  bile  from  the 
intestine. 

D.  Bacteria. — The  presence  of  tubercle  bacilli  may  be  demon- 
strated by  the  described  method  of  Strasburger  for  isolating  bacteria 
from  the  feces.  Tubercle  bacilli  have  a  predilection  for  mucous 
flakes  and  purulent  matter  if  such  occur  in  the  stools.  The  gran- 
ulose  iodin  fungi,  as  Schmidt  termed  them,  which  are  nearly  always 
present,  may  be  observed  in  the  microscopic  iodin  preparation 
in  cases  of  questionable  carbohydrate  fermentation  of  the  feces. 
Furthermore,  the  iodin  preparation  admits  of  the  easy  recognition 
of  yeast,  lactic  acid  bacteria,  and  sarcinse,  which  stain  yellow  with 
iodin. 


DEMONSTRATION  OF  BLOOD  IN  THE  FECES  123 

THE  DEMONSTRATION  OF  BLOOD  IN  THE  FECES. 

Admixtures  of  large  quantities  of  blood  are  maeroseopically 
recognizable  by  the  well-known  tax-black  color  of  the  feces. 

The  following  chemical  methods  serve  to  demonstrate  the  smallest 
occult  hemorrhages,  such  as  are  of  frequent  occurrence  in  gastric 
and  duodenal  ulcer,  and  the  diagnosis  of  which  is  sometimes  decided 
by  them.  Blood  originating  from  the  stomach  or  the  upper  intes- 
tinal tract  is  excreted  as  hematin;  on  this  fact  is  based  the  chemical 
demonstration  of  blood. 

Hematin  can  be  found  with  the  spectroscope.  Ether,  which  in 
the  presence  of  hematin  is  of  a  brownish  hue,  will  show  the  spectrum 
of  acid  hematin.  This  has  an  intense,  narrow  stripe  of  red  between 
C  and  D,  but  considerably  less  pronounced  than  the  latter;  also 
three  stripes  of  yellow  on  the  borderlines  between  yellow  and  green 
and  between  green  and  blue.  The  latter,  as  a  rule,  can  only  with 
difficulty  be  distinguished. 

Occult  Blood. — It  has  been  known  for  some  time  that  in  ulcer 
or  carcinoma  of  the  stomach  there  is  always  slight  gastric  hemor- 
rhage. Clinicians  have  been  unable  to  tell  definitely  whether  the 
blood  found  in  the  stomach  contents  came  from  the  neoplasm  or 
was  due  to  irritation  by  the  stomach  tube.  The  slightest  irritation 
by  the  stomach  tube  would  produce  a  small  amount  of  invisible 
blood,  which  would  respond  to  the  chemical  test.  Boas  was  the 
first  to  examine  the  feces  for  invisible  blood;  he  knew  the  blood 
corpuscles  would  degenerate,  and  the  hematin  crystals  should  be 
found  in  the  feces.  If  these  hematin  crystals  could  be  found  in 
the  feces,  with  other  signs  of  either  ulcer  or  carcinoma,  the  test 
would  be  valuable.  Examination  for  invisible  blood  in  the  feces 
is  of  great  importance,  since  many  clinicians  report  the  constant 
presence  of  occult  blood  in  cases  of  gastric  ulcer  and  carcinoma. 
The  term  "occult  blood"  is  applied  to  minute  hemorrhages  dis- 
charging in  the  gastro -intestinal  canal,  too  small  to  be  discerned 
maeroseopically.  By  the  time  the  blood  passes  through  the  whole 
intestinal  canal  the  corpuscles  are  so  broken  down  that  they  cannot 
be  found  with  the  microscope.  The  tests  for  occult  blood  are  chemi- 
cal. Since  they  are  extremely  sensitive,  very  small  amounts  of  blood 
can  be  detected.  There  is  great  liability  to  error  in  determining 
the  site  of  the  hemorrhage.  Besides  epistaxis,  hemoptysis,  and 
hemorrhoids,  any  foodstuff  containing  hemoglobin  in  any  amount 
will  give  the  reaction.  Therefore  the  diet  must  be  a  blood-free 
one  for  three  days  previous  to  the  test. 

Benzidin  Test  for  Occult  Blood.— This  test  is  very  sensitive.  It 
was  first  described  by  O.  and  R.  Adler,  and  has  been  subjected  to 
slight  modifications  by  Schlesinger  and  Hoist.  The  test  is  made  as 
follows: 

I.  One  gram  of  benzidin  is  placed  in  a  test  tube  with  about  2  Cc.  of 
glacial  acetic  acid.    This  mixture  should  be  freshly  prepared. 


124  EXAMINATION  OF  THE  FECES 

II.  A  small  piece  of  feces  (the  size  of  a  pea)  is  rubbed  up  with 
water  and  placed  in  a  test  tube  and  boiled;  boiling  destroys  the 
oxidizing  ferments. 

III.  To  about  3  Cc.  of  peroxid  of  hydrogen  in  a  test  tube,  add 
about  five  drops  of  the  above  glacial  acetic  acid-benzidin  mixture, 
and  lastly  a  few  drops  of  the  boiled  feces. 

Blood  is  indicated  by  a  greenish  or  blue  color  (Plate  IX). 

Phenolphthalein  Ring  Test  for  Occult  Blood. — Boas  prefers  the 
phenolphthalein  test  for  occult  hemorrhages  of  the  gastro-intestinal 
canal.  He  points  out  that  the  benzidin  test,  which  demonstrates 
blood  in  a  dilution  of  1  to  200,000,  is  altogether  too  delicate;  it 
indicates  the  minutest  quantities  of  alimentary  (exogenous)  blood, 
and  the  reaction  may  be  distinctly  positive  after  three  or  four  days 
of  meat-free  diet.  Weber's  guaiac  test  (page  86)  is  less  susceptible, 
but,  inasmuch  as  the  substances  which  disturb  the  test  must  be 
extracted  by  alcohol  and  ether,  there  are  certain  difficulties  in  the 
way  of  its  practical  application  not  present  in  the  phenolphthalein 
test.  The  phenolphthalein  test  is  based  on  the  fact  that  phenol- 
phthalein, in  an  alkaline  solution,  is  oxidized  by  blood  pigment  so 
that  the  solution  becomes  pink  or  red.  The  phenolphthalein 
reagent  is  prepared  as  follows:  1  gram  of  commercial  phenol- 
phthalein and  25  grams  of  potassium  hydrate  are  dissolved  in  100 
Cc.  of  water,  and  to  this  solution  10  grams  of  zinc  powder  are 
then  added.  The  mixture,  which  is  at  first  red,  is  boiled  over  a 
small  flame  (about  two  hours  if  necessary)  under  constant  stirring 
and  shaking  until  complete  decoloration  has  taken  place  by  reduc- 
tion. The  hot  solution  is  then  filtered.  For  preservation  a  small 
excess  of  zinc  powder  may  be  added. 

The  demonstration  of  blood  is  carried  out  as  follows:  Fifteen 
drops  of  phenolphthalein  reagent  are  put  into  a  beaker  and  five  or 
six  drops  of  a  3-per-cent.  hydrogen  peroxid  solution  added.  Then 
add  2  Cc.  of  absolute  alcohol,  and  shake.  Some  of  the  extract 
of  the  feces  (made  by  extracting  them  with  a  mixture  consist- 
ing of  five  drops  of  glacial  acetic  acid  and  15  to  20  Cc.  of  abso- 
lute alcohol)  is  then  filtered  through  a  common  filter  into  the 
reagent  glass,  the  funnel  being  so  placed  with  respect  to  the  glass 
that  the  filtrate  will  come  in  contact  with  the  solution  at  the 
margin.  If  blood  be  present,  a  pink  or  deep  red  ring  will  appear 
at  once  or  gradually,  according  to  the  amount  of  blood.  By  placing 
the  beaker  on  a  pure  white  surface,  the  red  line  is  brought  out 
more  distinctly  by  contrast.  The  principal  advantage  of  this  test 
consists  in  the  characteristic  reaction,  the  possibility  of  differen- 
tiating between  the  presence  of  large  and  small  quantities  of  blood, 
the  permanency  of  the  reagent,  and  simplicity  of  preparation. 

In  point  of  acuity,  the  phenolphthalein  test  stands  between 
Weber's  guaiac  and  the  benzidin  test.  If  the  benzidin  or  phenol- 
phthalein test  is  to  be  employed,  a  preparatory  period  of  several 
days  of  meat-free  diet  must  be  insisted  upon. 


PLATE    IX 


KIG.  2 


? 


Benzidin  Test. 

Fig.   1.      Faint  reaction.  Fig.  2.      Marked  reaction. 


DEMONSTRATION  OF  FERMENTS  IN  THE  FECES         L25 

THE  DEMONSTRATION  OF  FERMENTS  IN  THE  FECES. 

In  intestinal  affections  in  which  the  differential  diagnosis  of  a 
pancreatic,  affection  is  involved,  it  is  important  to  examine  the 
stool  for  pancreatic  ferments,  as  their  absence  or  presence  will 
decide  the  diagnosis  under  certain  circumstances. 

Trypsin. — The  Plate  Test  of  Miiller-ScMecht. — If  a  few  small 
drops  of  the  test  material  be  placed  upon  the  surface  of  a  so-called 
Loeffler  serum  plate,  and  this  plate  be  kept  in  an  incubator  at  a 
temperature  of  50°  to  60°  C,  there  will  occur  slight  but  gradually 
increasing  indentations  if  trypsin  be  present.  In  the  absence  of 
the  ferment  juice  there  will  be  no  such  indentations. 

The  Casein  Method  of  Gross. — The  principle  of  this  method  is 
based  upon  the  fact  that  casein,  which  is  easily  soluble  in  a  weak 
alkaline  solution,  is  readily  precipitated  upon  the  addition  of  dilute 
acetic  acid.  For  purposes  of  fecal  examination  a  0.5-per-cent. 
solution  of  casein  is  prepared  by  dissolving  0.5  Gm.  of  pure  casein 
(Gruebler)  in  one  liter  of  a  1-per-cent.  sodium  hydrate  solution  by 
heat.  The  feces  are  mixed  in  a  mortar  with  a  treble  quantity  of  a 
1-per-cent.  sodium  hydrate  solution  until  a  uniform  mass  is  obtained, 
and  filtered  until  a  clear  yellow  filtrate  appears,  which  is  usually 
in  a  short  time.  If  the  resulting  filtrate  is  not  quite  clear,  the  tur- 
bid element  is  allowed  to  settle  and  the  supernatant  clear  liquid  is 
used.  One  hundred  cubic  centimeters  of  the  casein  solution  is  placed 
in  a  small  retort,  10  Cc.  of  the  fecal  preparation  added,  and  the 
mixture  placed  in  a  thermostat  at  38°  to  40°  C.  By  taking  samples 
from  time  to  time  it  will  be  found  that  no  more  turbidity  occurs 
upon  the  addition  of  a  1-per-cent.  acetic  acid  solution  when  all  of 
the  casein  has  been  digested — proving  the  presence  of  trypsin. 

It  has  been  found  that  in  all  cases  where  there  is  no  affection  of 
the  pancreas  or  occlusion  of  the  pancreatic  excretory  ducts,  trypsin 
is  demonstrable  in  the  feces.  In  order  to  obtain  a  high  percentage 
of  trypsin  in  the  feces,  a  strongly  protein  diet  or  a  mild  laxative 
should  be  administered.  The  digestive  period  of  casein  is  between 
eight  and  fifteen  hours;  usually  it  is  from  twelve  to  fourteen  hours. 
It  is  possible  to  draw  approximate  quantitative  conclusions  from 
appropriate  fecal  dilutions. 

Steapsin. — To  10  Cc.  of  distilled  water  in  a  small  flask  are 
added  1  Cc.  stool  filtrate,  1  Cc.  ethyl  butyrate,  and  1  Cc.  toluol. 
One  drop  of  a  1-per-cent.  alcoholic  solution  of  phenolphthalein  is 
now  added,  and  the  mixture  made  neutral  with  a  deeinormal 
sodium  hydrate  solution.  Add  water  to  bring  the  fluid  to  25  Cc, 
cork,  shake,  and  incubate  for  twenty-four  hours  at  40°  C.  After 
incubation  the  mixture  is  titrated  to  neutral  again  with  a  deci- 
normal sodium  hydrate  solution.  A  control  is  made  by  using  stool 
filtrate  which  has  been  boiled  for  five  minutes.  The  difference 
between  the  amount  of  free  acid  which  has  developed  in  the  control 


126  EXAMINATION  OF  THE  FECES 

flask  and  that  which  has  developed  in  the  test  flask  is  an  index  of 
the  fat-splitting  ferment  present  in  the  latter. 

Demonstration  of  the  presence  of  steapsin  in  the  intestinal  con- 
tents is  also  made  by  either  of  two  methods,  the  Grutzner-Gamgee 
or  the  von  Oefele. 

By  means  of  the  former  the  fat-splitting  ferment  manifests 
itself  by  the  change  in  color  which  it  produces  in  a  mixture  of  oil- 
gum  emulsion  and  neutral  litmus  solution.  The  emulsion  consists 
of  10  parts  of  oil,  5  of  gum,  and  35  of  water;  the  litmus  solution 
in  12-m.m.  test  tubes  shows  violet  against  white  paper.  In  each  of 
several  such  test  tubes  10  Cc.  of  the  litmus  solution  and  5  drops  of 
the  emulsion  are  placed,  and  graded  amounts  (from  2  to  32  drops)  of 
the  fluid  to  be  tested  are  added.  The  tubes  are  then  placed  in  a 
water -bath  at  37°  C,  and  after  a  few  minutes  examined.  Redness, 
more  or  less  pronounced  according  to  the  amount  of  intestinal  fluid 
added,  is  proof  of  the  presence  of  the  fat -splitting  ferment. 

By  von  Oefele's  method  the  steapsin  in  the  intestinal  juice 
tested  dissipates  the  red  tint  of  a  mixture  of  melted  sweet  butter, 
potassium  carbonate  and  phenolphthalein  titrated  with  a  soda 
solution  until  it  becomes  red.  The  melted  butter  is  mixed  with  an 
equal  amount  of  a  1-per-cent.  aqueous  solution  of  potassium  car- 
bonate, with  a  little  phenolphthalein  added.  Heated  to  55°  C.,  5  Cc. 
of  this  liquid  is  then  shaken  in  a  warm  test  tube  with  5  drops  of 
intestinal  fluid.  Normally  the  red  color  will  disappear  in  two  to  five 
minutes,  as  a  result  of  the  action  of  the  steapsin  present. 

The  Nuclei  Test  of  Adolf  Schmidt. — Schmidt  found  that  the  cellu- 
lar nuclei,  unlike  the  connective  tissue,  are  digested  by  the  pancreatic 
secretion  only,  and  not  by  the  gastric  juice.  If,  therefore,  undi- 
gested tissue  nuclei  reappear  in  the  feces,  we  may  conclude  that  the 
pancreatic  function  is  defective. 

The  test  is  made  in  the  following  way:  The  patient  swallows  for 
several  consecutive  days  a  small  cube  of  meat  enveloped  in  a  bag 
of  silk  gauze.  These  silk  bags  are  easily  recognized  in  the  feces, 
especially  if  the  tying  silk  thread  be  long.  The  meat  remnants 
contained  in  the  little  bags  are  examined  for  the  presence  of  nuclei, 
either  in  their  original  condition  by  treatment  with  acetic  acid  or 
methylene  blue,  or,  after  hardening,  in  stained  sections. 

The  meat  cubes  are  cut  from  fresh  meat;  they  are  about  one- 
half  centimeter  long  and  are  preserved  in  alcohol.  After  harden- 
ing, they  are  placed  in  the  small  silk  bags  and  again  preserved  in 
alcohol.  Before  use,  the  bags,  with  their  contents,  should  be  dehy- 
drated for  several  hours.  Strauch1  has  verified  the  nuclei  test  in 
Abderhalden's  Physical  Institute  with  pure  digestive  juice  obtained 
from  a  dog  through  a  stomach  fistula,  and  arrived  at  the  following 
results:  Pure  gastric  juice    (pepsin  and  hydrochloric  acid)  leaves 

1  Deutsches  Archiv  f.  klin.  Medizin,  vol.  ci,  Nos.  1  and  2. 


DEMONSTRATION  OF  FERMENTS  IN  THE  FECES         127 

tissue  nuclei  unchanged.  Pure  pancreatic  juice  ('trypsin!  com- 
pletely dissolves  cell  nuclei  within  six  to  eight  hours.  Pure  intes- 
tinal juice  (erepsin)  does  not  influence  cell  nuclei.  Juice  pressed 
from  the  intestine  will  dissolve  cell  nuclei,  but  only  at  a  slow  rate. 
Thus  the  correctness  of  the  basis  upon  which  Schmidt's  nuclei  test 
rests  has  been  demonstrated. 

Diastase  Test  (Wohlgemuth). — The  diastase  is  demonstrated  by 
testing  the  dextrinizing  influence  of  a  present  diastase  upon  a 
starch  solution,  an  iodin  solution  serving  as  indicator. 

This  is  done,  according  to  Wohlgemuth,  in  the  following  manner: 
A  weighed  quantity  of  5  grams  of  fresh  feces  is  triturated  in  a 
mortar  with  20  Cc.  of  a  1-per-cent.  solution  of  sodium  chlorid; 
at  first  only  a  few  cubic  centimeters  of  the  measured  quantity 
of  sodium  chlorid  solution  are  added  to  the  mass,  which  is  tritu- 
rated until  a  perfectly  homogeneous  product  results;  and  this  is 
continued  until  all  of  the  liquid  has  been  triturated  with  the  feces. 
This  mixture  is  allowed  to  stand  at  room  temperature  for  thirty 
minutes,  during  which  time  it  should  be  frequently  stirred  up. 
The  liquid  mass  is  then  uniformly  distributed  into  two  centrifuge 
tubes  (10  Cc.  in  each)  exactly  marked  and  graduated.  The  tubes 
are  rotated  until  the  solid  parts  have  settled,  which  will  be  in  five 
to  ten  minutes,  and  the  height  of  the  solid  sediment  and  of  the 
liquid  is  read  off  the  graduated  tubes  and  noted.  The  supernatant 
ferment-containing  fecal  extract  is  poured  off,  and  the  diastase 
determined  by  a  series  of  tests.  For  this  purpose  the  liquid  is  dis- 
tributed over  nine  test  tubes:  the  first  three  tubes  will  receive  1, 
0.5,  and  0.25  Cc,  respectively,  of  the  undiluted  fecal  extract,  and 
this  procedure  is  continued  so  that  each  succeeding  tube  wili  receive 
one-half  the  quantity  contained  in  the  preceding  one.  This  object 
is  most  conveniently  attained  if  an  eighth  and  a  sixty-fourth  dilu- 
tion of  the  original  fecal  extract  be  worked  with.  Tubes  -4,  5 
and  6  will  then  receive  1,  0.5,  and  0.25  Cc.  of  the  one-eighth  dilu- 
tion; tubes  7,  8  and  9,  1,  0.5,  and  0.25  Cc.  of  the  one-sixty-fourth 
dilution.  All  the  dilutions  are  made  with  a  1-per-cent.  solution  of 
sodium  chlorid,  and  all  the  tubes  are  brought  up  to  1  Cc.  in  volume 
by  the  same  solution  in  order  to  obtain  throughout  a  uniform 
concentration  of  sodium  chlorid.  Then  5  Cc.  of  a  1-per-cent. 
starch  solution  is  added  to  each  test  tube.  The  tubes  are  then 
tightly  closed  with  a  cork  or  cotton  plug  and  kept  in  the  incubator 
at  38°  C.  for  twenty-four  hours.  This  period  having  elapsed,  they 
are  taken  out  and  cold  water  from  the  tap  is  added  up  to  a  finger's 
width  from  the  bottom.  To  each,  one  drop  of  a  decinormal  iodin 
solution  is  added,  and  the  lowest  limit  of  diastatic  efficiency  is 
exhibited  by  the  tube  in  which  a  blue  coloration  appears  first. 

Fat-digestion  Tests. — Steatorrhea,  or  increased  fat  in  the  stools, 
occurs  not  only  in  icterus,  but  in  pancreatic  disease.  The  stools 
are  of  a  light  color,  often  voluminous  and  of  a  rancid  odor;  if  many 


128  EXAMINATION  OF  THE  FECES 

fat  crystals  are  present  they  may  impart  an  aluminum-like  appear- 
ance to  the  stools.  A  phenomenon  that  is  said  to  be  quite  charac- 
teristic of  defective  pancreatic  secretion  is  the  passage  of  colorless 
liquid  stools  which  harden  on  cooling.  The  bile  which  normally 
finds  its  way  into  the  intestine  prepares  the  fats,  by  emulsification, 
for  the  action  of  the  pancreatic  lipase;  so  that  even  though  as  much 
as  60  per  cent,  of  the  fats  ingested  be  found  in  the  stools,  there  is 
not  necessarily  any  pancreatic  defect — the  fault  may  be  with  the 
liver.  Normally,  as  much  as  10  or  11  per  cent,  of  the  ingested 
fats  passes  through  the  intestine  unchanged;  an  amount  in  excess 
of  this  indicates  icterus  or  pancreatic  insufficiency.  To  estimate 
the  amount  of  fat  in  the  stools,  both  microscopic  and  chemical 
methods  are  employed — the  latter  in  case  the  former  is  inadequate. 
The  microscope  reveals  the  fat  as  droplets,  needle-like  crystals,  or 
flakes.  For  accurate  quantitative  estimation  of  fats,  the  feces  are 
dried  on  a  water-bath,  the  fatty  acids  and  neutral  fats  extracted 
with  ether,  the  residue  treated  with  dilute  hydrochloric  acid  to 
convert  any  soaps  that  may  be  present  into  fatty  acids,  and  these 
in  turn  extracted  with  ether.  By  measuring  the  dried  feces  to  be 
treated,  percentage  results  are  obtained. 

The  fat-splitting  function  of  the  pancreas  may  be  tested  with 
artificial  compounds  of  iodin  and  fat,  for  steapsin  possesses  the 
power  to  decompose  such  compounds.  If  5  Cc.  of  calcium  mono- 
iodobehenate  (sajodin)  be  taken  with  the  meal,  iodin  will,  we 
are  told  by  Syring,  appear  in  the  urine  within  three  to  five  hours 
in  all  normal  individuals.  Icterus  as  well  as  pancreatic  insufficiency, 
however,  prevents  its  appearance.  The  iodin  test  was  introduced 
by  Winternitz. 

Carmin  or  Charcoal  Test. — In  order  to  determine  the  motility  of 
the  intestine,  certain  substances  which  color  the  feces  are  given  at 
a  definite  time,  and  the  evacuations  are  watched  to  ascertain  the 
interval  necessary  for  these  substances  to  appear.  Charcoal  colors 
the  feces  black.  Carmin  colors  them  red.  By  administering  a 
dose  of  charcoal  or  carmin  at  the  commencement  of  an  intestinal 
test  diet,  we  are  able  to  mark  off  the  moment  when  it  begins  to 
appear  in  the  stools,  and  when  we  may  safely  use  the  latter  for 
purposes  of  examination.  We  may  mark  off  and  obtain  the  total 
feces  corresponding  to  a  test  diet  extending  over  a  fixed  period  by 
giving  a  carmin  capsule  0.5  Gm.  (7^  grains)  at  its  commencement 
and  another  at  its  termination.  As  Basch  remarks,  in  the  carmin 
test  we  have  a  simple,  harmless,  reliable  and  convenient  means  for 
the  demarcation  of  stools  and  the  estimation  of  gastro-intestinal 
motility  and  patency,  for  the  detection  of  fistulous  communica- 
tions of  the  alimentary  canal  with  the  exterior  or  with  other  hollow 
organs,  for  the  location  of  the  distal  end  of  a  duodenal  tube,  and 
to  aid  in  the  differentiation  between  esophageal  diverticulum  and 
dilatation. 


DEMONSTRATION  OF  FERMENTS  IN  THE  FECES         129 

Sahli's  Glutoid  Capsule  Test. — In  order  to  ascertain  the  chemical 
activity  of  the  small  intestine,  Sahli  employs  a  glutoid  capsule. 
These  capsules  are  made  from  gelatin  (glutoid)  hardened  with 
formaldehyde.  They  do  not  dissolve  in  the  gastric  juice  at  all,  or 
only  after  a  considerable  time,  hut  are  rather  quickly  soluble  in 
pancreatic  digestive  mixtures.  They  are  utilized  to  diagnose  the 
condition  of  the  pancreatic  function.  These  capsules  are  filled 
with  material  which  is  normally  eliminated  in  the  saliva  or  urine. 
Iodoform,  according  to  Sahli,  has  given  the  best  results;  it  is 
absorbed  from  both  the  stomach  and  the  intestine  in  from  fifteen 
minutes  to  an  hour  and  a  quarter  after  ingestion.  Fifteen  centi- 
grams (2  grains)  of  iodoform  will  usually  give  a  marked  iodin 
reaction  in  the  saliva  or  in  the  urine  with  the  usual  chloroform, 
sodimn  nitrite  and  sulphuric  acid  test.  Iodoform  has  the  great 
advantage  that  it  cannot  penetrate  the  glutoid  capsule;  the  cap- 
sule must  be  dissolved  before  it  can  be  liberated.  In  normal  gastric 
motility,  in  normal  intestinal  digestion,  and  in  normal  intestinal 
absorption,  the  iodin  reaction  may  be  expected  to  appear  in  the 
saliva  and  urine  in  four  to  six  hours. 

Three  hours  after  administration  of  the  glutoid  capsule  filled 
with  iodoform,  and  at  irregular  intervals  thereafter,  the  patient 
expectorates  saliva,  or,  better,  voids  urine  in  numbered  beakers. 
These  specimens  are  examined  for  the  presence  of  iodin.  Sahli 
prefers  the  urine  test  because  of  the  irregularity  of  iodin  elimination 
with  the  saliva. 

Einhorn's  Bead  Test. — Einhorn  describes  a  method  of  estimating 
the  motor  functions  of  the  digestive  apparatus.  It  consists  in 
having  the  patient  swallow  a  number  of  small  porcelain  or  glass 
beads  (Plate  X),  and  noting  the  time  that  elapses  between  the 
taking  of  the  beads  and  their  appearance  in  the  stool.  Solid  food- 
stuffs are  attached  to  glass  or  porcelain  beads  by  being  drawn 
through  the  opening  in  the  bead  and  tied  on  with  a  silk  thread; 
obviously  on  passing  through  the  stomach  and  bowel,  the  substance 
attached  to  the  bead,  if  entirely  digestible,  will  have  disappeared, 
whereas  indigestible  substances  will  be  found  in  the  feces  attached 
to  the  bead.  It  is  possible  in  this  way  to  ascertain  the  digestibility 
of  many  food  substances  in  normal  as  well  as  in  pathologic  conditions. 

Six  test  substances  are  usually  attached  to  the  beads:  (1)  catgut; 
(2)  fishbone;  (3)  meat;  (4)  potato;  (5)  mutton  fat;  (6)  thymus 
gland.  Physiologically,  the  first  two  substances  (catgut  and  fish- 
bone) are  usually  digested  in  the  stomach  and  the  remaining  four 
(meat,  potato,  mutton  fat,  thymus)  in  the  intestine. 

All  the  beads  usually  appear  in  the  stool  under  normal  conditions 
in  one  or  two  days,  either  all  empty  or  with  a  trace  of  fat  or  thymus 
(or  fishbone)  left.  Deviations  from  this  rule  point  to  pathologic 
conditions. 

With  regard  to  the  functions  of  the  digestive  apparatus  the 
9 


130  EXAMINATION  OF  THE  FECES 

following  conclusions  may  be  drawn :  In  case  all  the  beads  emerge 
in  a  much  shorter  time  than  twenty-four  hours,  there  is  an  acceler- 
ated motility;  if  they  emerge  after  forty-eight  hours,  a  retarded 
motility  exists.  The  digestive  function  is  good  if  all  the  beads  are 
empty  or  if  there  are  but  traces  of  fat  or  thymus  (also  fishbone) 
left.  A  reappearance  of  catgut  or  meat,  potato,  much  fat  or  much 
thymus,  always  indicates  a  poor  digestive  function  for  the  food 
substance  in  question.  If  all  these  test  substances  reappear  in  the 
stool,  an  absolutely  poor  digestive  function  exists. 

Preparation  of  Food  Beads. — (1)  Catgut:  Take  raw  catgut  No.  00, 
draw  it  through  the  bead,  and  tie  the  ends  together  (Plate  X,  a). 
(2)  Fishbone:  As  the  ordinary  fishbone  breaks  when  tied  in  a  knot, 
it  is  best  to  use  the  long  bones  from  a  pickled  herring.  The  bones 
are  washed  in  water  first,  then  rubbed  off  with  a  cloth,  and  kept 
in  water  in  a  bottle.  When  wanted,  they  are  taken  out  of  the 
water,  drawn  through  the  bead,  and  tied  in  the  same  manner  as 
the  catgut  (Plate  X,  c).  (3)  Meat:  The  muscle  fibers  of  raw  beef 
are  cut  lengthwise  in  the  direction  of  the  fibers  and  in  pieces  5  to 
6  centimeters  (about  2  inches)  long,  and  1  centimeter  (§  inch) 
thick.  These  are  preserved  in  a  bottle  of  alcohol.  Take  a  piece 
of  meat  from  the  alcohol  bottle,  tear  off  lengthwise  a  muscle  fiber 
2  or  3  centimeters  long  and  1  millimeter  (^  inch)  thick,  draw 
it  through  the  bead  and  allow  the  ends  to  overlap;  next  tie  the 
ends  fast  together  over  the  bead  with  a  silk  thread  (Plate  X,  e). 
(4)  Thymus:  Raw  sweetbread  from  the  calf  is  cut  in  cubes  and 
preserved  in  alcohol.  For  use,  lay  a  small  piece,  about  2  cubic 
millimeters,  within  a  small  square  of  gauze,  fold  the  four  ends  of 
the  gauze  together  and  tie  with  thread,  so  that  the  small  piece  of 
thymus  lies  enclosed  as  in  a  purse;  then  fasten  the  gauze  purse  to 
a  bead  (Plate  X,  b).  (5)  Mutton  fat:  Beads  with  a  large  opening 
(1.5  or  2  millimeters  in  diameter)  should  be  dropped  in  hot  rendered 
mutton  fat  and  after  a  minute  taken  out  with  a  forceps  and  placed 
in  a  vessel  of  cold  water.  This  congeals  the  fat.  Then  they  are 
laid  on  a  piece  of  pure  filter  paper  and  allowed  to  remain  until 
thoroughly  dried.  The  beads  can  then  be  kept  as  long  as  desired, 
and  are  ready  when  wanted  for  use  (Plate  X,  /).  (6)  Potato: 
Cook  a  piece  of  potato  with  the  peel  on  in  boiling  water  two  min- 
utes. Take  out  of  the  water  and  cool.  Now  cut  a  small  piece  of 
the  potato  with  peel,  1  centimeter  (\  inch)  long,  0.5  centimeter  wide, 
and  1.5  or  2  millimeters  (yw  or  tj  inch)  thick,  and  attach  it  to  a 
bead  (Plate  X,  d) .  Two  or  more  food  substances  may  be  attached 
to  one  bead;  for  instance,  catgut  and  fishbone,  meat  and  thymus. 
The  test  beads  can  all  be  kept  on  hand  with  the  exception  of  the 
potato,  which  must  always  be  freshly  prepared.  Meat  and  thymus 
beads  are  best  kept  in  alcohol.  Catgut,  fishbone  and  fat  beads 
are  simply  preserved  dry.  The  beads,  when  prepared,  should  be 
strung  together,  and  the  string  placed  in  a  gelatin  capsule  and 


PLATE    X 


Bead  String. 

a,  eatgut  bead;  b,  thymus  bead;  c,  fishbone  bead;  d,  potato  bead;  e,  meat  bead; 
/,  mutton-fat  bead;  g,  bead-test  capsule. 


TEST-DIET  STOOL  FINDINGS  131 

so  administered,  best  shortly  after  a  meal  (Plate  X,  g).  The 
bead  test  gives  a  very  fair  idea  of  how  long  the  food  remains  in 
the  intestinal  tract,  which  the  test  diet  does  not.  The  bead  test  is 
designed  to  show  the  digestibility  of  protein,  fat,  and  carbohydrate, 
and  the  motility  of  the  gastro-intestinal  tract. 

THE  TEST-DIET  STOOL  FINDINGS  IN  GASTRIC  AND 
INTESTINAL  AFFECTIONS. 

ACHYLIA  GASTRICA  AND   SUBACIDITY. 

(a)  Slight  goitrogenic  disturbances  of  the  intestine,  or  none  at  all. 
The  exterior  aspect  of  the  stool  resembles  the  normal  in  all  respects. 
Connective  tissue  is  more  or  less  abundant.  On  microscopic  exam- 
ination small  connective-tissue  fibers  are  seen,  which  may  be  the 
expression  of  insignificant  absorptive  disturbances  of  the  small 
intestine;  fat  somewhat  increased,  fatty  soap  needles,  increased 
muscle  fibers.     Chemical  examination  normal. 

(b)  Pronounced  gastrogenic  intestinal  disturbances.  In  this  con- 
dition the  stool  loses  its  concentrated  form  and  is  thin  or  diarrheic; 
for  this  reason  a  uniform  picture  of  the  stool  cannot  be  given. 
Macroscopically  there  is  always  some  connective  tissue,  which  fre- 
quently coheres  with  the  meat  remnants.  At  the  same  time  the 
greatest  variety  of  catarrhal  conditions  of  large  and  small  intes- 
tine, fermentation  of  carbohydrates,  or  protein  putrefaction,  may 
exist.  The  demonstration — if  need  be,  microscopic — of  yeast, 
sarcina?,  and  long  bacilli,  is  of  importance. 

Hyperacidity. 

Feces  either  normal,  or  pathologic  as  in  atonic  constipation.  In 
rare  cases  connective  tissue  (pepsin  insufficiency?) 

Gastric  Ulcerand  Gastric  Carcinoma. 
Occult  blood. 

Chronic  Catarrh  of  the  Small  Intestine. 

(a)  Mii,d  Cases. — Stool  formed  or  massy.  Small  potato  remnants, 
isolated  potato  cells.  Minute  muscle  fragments.  Fat  increased. 
Small  mucous  flakes  of  the  small  intestine. 

Microscopic:  Abundant,  poorly  digested  muscle  fibers.  Abun- 
dant potato  cells,  with  and  without  starch.  Fatty  soap  and  fatty 
acid  needles. 

Chemical:  Reaction  increased  alkaline  or  acid,  according  to  the 
predominance  of  protein  putrefaction  or  carbohydrate  fermentation. 

Sublimate  test:  Red  coloration. 


132  EXAMINATION  OF  THE  FECES 

Incubation  test:  Negative,  or  protein  putrefaction.  Rarely 
carbohydrate  fermentation. 

Dissolved  protein:  Negative,  or  weakly  positive. 

(b)  Grave  Cases. — Thin,  watery  stool,  of  green  color  in  the  more 
serious  conditions,  otherwise  dark  brown,  malodorous.  Meat  rem- 
nants small  or  large.  Numerous  isolated  potato  cells  and  rather 
large  potato  pieces.  Much  fat,  possibly  fat  lumps.  Abundant 
mucous  flakes  of  the  small  intestine,  which  may  show  a  biliary  dis- 
coloration. 

Microscopic:  Abundant  muscle  fibers,  oftentimes  strongly  satu- 
rated with  bile.  Potato  cells  with  and  without  starch.  Free  starch 
granules.  Abundant  fat  (fatty  acid,  soap  needles,  also  neutral  fat 
in  some  of  the  severest  cases) .  Minute  mucous  flakes.  Ammonio- 
magnesium  phosphate  (protein  putrefaction). 

Chemical:  Reaction  alkaline. 

Sublimate  test:  Green  coloration  either  of  the  entire  feces  or  of 
some  macroscopic  or  microscopic  particles. 

Incubation  test:  Pronounced  putrefaction.    Rarely  fermentation. 

Dissolved  protein:  Strongly  positive. 

Bacteria:  Cocci  in  protein  putrefaction,  proteus,  Bacillus  fluo- 
rescens,  etc. 

Chronic  Catarrh  of  the  Large  Intestine. 

(a)  Mild  Cases.— Stool  formed,  massy,  or  thin,  of  normal  color. 
Large  and  medium-sized  mucous  flakes  of  the  large  intestine. 

Microscopic:  Nothing  of  consequence. 

Chemical:  Reaction  normal. 

Sublimate  test:  Red  coloration. 

Incubation  test:  Normal,  or  slight  decomposition. 

Dissolved  protein:  Perhaps  weakly  positive. 

(b)  Grave  Cases. — Diarrheic,  watery  stools,  malodorous,  of  dark 
brown  or  more  frequently  light  color.  Large  quantities  of  mucus 
in  large  and  small  flakes,  non-transparent,  whitish,  sometimes 
sanguineous. 

Microscopic:  No  peculiarities  to  notice. 

Chemical:  Reaction  usually  alkaline. 

Sublimate  test:  Red  coloration. 

Incubation  test:  Putrefaction. 

Dissolved  protein :  Positive. 

Frequently  both  the  small  and  the  large  intestine  are  inflamed, 
and  the  feces  are  correspondingly  composed;  they  may  be  construed 
from  the  above  stool  pictures.  The  feces  in  acute  catarrh  of  the 
small  and  the  large  intestine  also  correspond  to  the  description 
given  above.  If  achylia  or  subacidity  is  present,  the  findings  of 
connective  tissue  should  be  added  in  order  to  obtain  the  stool 
picture  of  gastrogenic  diarrhea. 


TEST-DIET  STOOL  FINDINGS  133 

Dysentery. 

In  dysentery  there  is  the  pieture  of  the  gravest  kind  of  catarrh 
of  the  large  intestine  complicated  by  abundant  admixture  of  blood 
in  the  stool,  and  sanguineous  mucus  (red  dysentery)  or  pus  (white 
dysentery).  Oftentimes  the  intestinal  evacuation  consists  of  noth- 
ing but  pus,  blood,  and  mucus,  mixed  with  small  particles  of  feces. 
If  there  is  simultaneous  catarrh  of  the  small  intestine,  the  symptoms 
of  disturbed  digestion  will  be  present  in  addition. 

Chemical :  Reaction  alkaline. 

Incubation  test:  There  is,  "of  course,  considerable  protein  putre- 
faction. 

Bacteria:  In  endemic  dysentery  the  Endameba  histolytica, 
Endameba  tetragena  or  the  Endameba  coli  of  Loesch  is  present 
and  can  be  seen  in  motion  in  the  mucous  flakes  under  the  warm 
microscope.  Occasionally  the  Balantidium  coli  is  found.  In 
epidemic  dysentery  there  is  the  Bacillus  Shiga-Kruse-Flexner. 

Intestinal  Tuberculosis. 

The  test-diet  stool  presents  the  picture  of  grave  catarrh  of  both 
the  large  and  the  small  intestine.    Further  findings  are: 

Macroscopic:  Pus. 

Microscopic:  Pus. 

Chemical:  The  blood  test  is  often  positive. 

Bacteria:  Tubercle  bacilli  in  the  bacterial  sediment,  mucus  and 
pus  flakes. 

Duodenal  Ulcer. 

Normal  feces.    Constipation  stool.    Occult  blood. 

Enteritis  Membranacea. 

The  characteristic  sign  consists  in  the  evacuation  of  mucus  in 
large  flakes  and  strings,  sometimes  without  any  feces.  However, 
the  feces  may  resemble  completely  the  normal  stool,  although  in 
most  cases  there  is  constipation  stool  (see  Atonic  and  Spastic 
Constipation).  Less  frequent  are  thin  and  diarrheic  stools  with 
no  signs  of  disturbed  digestion  of  the  small  intestine. 

Atonic  Constipation. 

A  very  small  quantity  of  hard,  dark  brown,  odorless  scybala. 
Over  their  surface  there  is  occasionally  a  brownish,  lac-like  film, 
with  small  traces  of  fresh  blood,  emanating  from  hemorrhoids. 

Macroscopic:  No  food  remnants,  nor  cellulose  remnants  such  as 
occur  in  the  normal  feces. 

Microscopic:  As  compared  with  the  normal  feces,  there  are  sur- 
prisingly few  remnants  of  muscle  fiber,  fat,  or  potato  cells;  and  there 
are  also  fewer  bacteria. 


134  EXAMINATION  OF  THE  FECES 

Chemical:  Reaction  neutral. 
Sublimate  test:  Red  coloration. 
Incubation  test:  No  reaction. 
Dissolved  protein:  Negative. 

Spastic  Constipation. 

In  spastic  constipation  the  feces  usually  correspond  to  the  normal 
feces;  they  are  evacuated  in  the  shape  of  small  or  large  hard  balls 
and  cylindrical  pieces  (sheep  feces),  which  are  often  covered  with  a 
mucous  film. 

Intestinal  Fermentation  Dyspepsia. 

The  stool  is  either  thin  or  massy,  of  yellow-green  or  golden- 
yellow  color,  of  an  intensely  acid  odor,  and  permeated  with  gas 
bubbles.  Large  quantities  of  potato  cells  are  found,  either  isolated 
or  coherent  in  the  shape  of  sago  clumps. 

Microscopic:  Numerous  potato  cells  in  the  field  of  vision,  filled 
with  starch,  in  the  iodin  preparation.  Numerous  free  starch 
granules. 

Chemical:  Reaction  strongly  acid. 

Sublimate  test:  Red  coloration. 

Incubation  test:  Strong  fermentation. 

Dissolved  protein:  Negative. 

Bacteria:  In  the  iodin  preparation  numerous  iodin  fungi,  stained 
blue.  Here  again  there  may  be  combinations  with  conditions  of 
catarrh  or  achylia,  which  would  effect  a  corresponding  change  in 
the  stool  picture. 

Nervous  Diarrhea. 

The  stool  either  consists  of  thin  masses  or  is  of  fluid  consistency, 
having  the  appearance  of  fresh  contents  of  the  small  intestine. 

Macroscopic  examination  reveals  numerous  undigested  food  rem- 
nants (muscle,  potato,  fat,  cellulose). 

Microscopic:   Numerous  undigested  food  remnants  of  all  kinds. 

Chemical:  Reaction  normal. 

Sublimate  test:  Red  coloration  or,  under  certain  circumstances 
and  considerably  accelerated  evacuation,  green  coloration. 

Incubation  test:  Negative. 

Dissolved  protein:  Negative. 

Stenoses  and  Intestinal  Carcinoma. 

The  stool  pictures  vary  considerably  according  to  whether  there 
is  diarrhea  or  chronic  constipation,  which  conditions  may  again  be 
complicated  by  catarrh.  Of  importance  are  admixtures  of  blood, 
sanguineous  mucus  and  pus,  which  may  also  be  macroscopically 
visible.    Furthermore,  occult  blood  is  to  be  considered. 


CHAPTER  V. 
ROENTGEN-RAY  EXAMINATION. 

By  filling  the  stomach  and  intestine  with  a  substance  opaque 
to  the  Roentgen  ray,  we  can  determine  the  size,  shape,  position  and 
motility  of  the  stomach,  and  visualize  the  outline  of  the  intestinal 
tract.  The  patient  partakes  of  a  meal  of  about  300  grams,  contain- 
ing about  60  grams  of  bismuth  subcarbonate  or  barium  sulphate. 
For  holding  these  salts  in  suspension,  buttermilk  is  usually  employed, 
although  potato-flour  soup  or  thin  porridge  can  be  used.  For  the 
detection  of  perforating  ulcer  of  the  stomach  and  to  permit  of  a 
more  Accurate  bringing  into  relief  of  small  defects,  it  is  now  con- 
sidered advisable  to  use  a  plain  water  suspension  of  barium  for  at 
least  the  first  half  of  the  meal.  For  an  accurate  roentgenograph^ 
examination  of  the  stomach,  the  patient  should  be  prepared  by 
fasting,  so  that  at  the  time  the  bismuth  or  barium  meal  is  given  the 
stomach  is  entirely  empty.  The  examination  should  not  be  made 
while  the  patient  is  under  the  influence  of  a  laxative  drug  of  any  kind, 
since  laxatives  interfere  with  the  ordinary  functioning  of  the  gastro- 
intestinal tract.  By  making  the  first  examination  in  the  morning 
the  behavior  of  the  stomach  can  be  observed  during  the  period  of 
emptying.  If  time  is  an  important  consideration,  as  in  hospital 
observations  where  a  number  of  cases  have  to  be  examined,  the 
so-called  double  meal  can  be  employed;  the  patient  is  given  the 
first  meal  very  early  in  the  morning,  and  examined  after  five  or  six 
hours  to  determine  the  time  of  emptying;  then  the  second  meal  can 
be  given  and  the  motility  of  the  stomach  observed.  Usually,  inspec- 
tion with  the  fluoroscope  will  consume  several  minutes,  the  ray 
being  turned  off  and  on  a  number  of  times.  The  second  examination 
is  usually  made  at  the  end  of  two  hours  after  the  second  meal  and 
again  three  hours  later.  Observations  are  also  made  at  the  end  of 
twelve  and  twenty-four  hours  respectively  and  at  such  intervals  as 
will  enable  the  roentgenologist  to  obtain  a  comprehensive  idea  of 
the  course  of  the  meal  from  its  ingestion  to  its  complete  expulsion. 

For  the  demonstration  of  small  lesions  about  the  pylorus  and  for 
the  proper  visualization  of  the  duodenal  bulb  if  it  shows  spasm  or 
defects,  it  is  essential  that  manipulation  of  the  stomach  be  prac- 
ticed during  fluoroscopy.  This  can  be  done  either  with  a  wooden 
spoon  or  preferably  with  the  hands,  protected  by  the  ray-proof 
glove.  The  manipulation  of  the  stomach  serves  to  accentuate 
defects  and  to  overcome  spasm.    If  an  organic  lesion  is  present  the 


136  ROENTGEN-RAY  EXAMINATION 

stomach  will  at  once  resume  its  pathologic  contour  after  manipula- 
tion has  been  practiced. 

Roentgen  fluoroscopy  supplements  the  roentgenogram,  as  it  gives 
immediate  information  regarding  the  changes  in  position  and  move- 
ments of  the  stomach  and  intestine;  the  observer  sees  these  changes 
while  they  are  being  enacted.  For  the  detailed  study  of  minute 
pathologic  alterations,  such  as  small  lesions  about  the  pylorus  and 
duodenal  cap,  the  roentgenogram  is  more  precise;  the  record  is  per- 
manent. By  taking  serial  roentgenograms  at  short  intervals  we 
obtain  most  valuable  information.  By  comparing  the  erect  with 
the  Trendelenburg  position,  the  presence  of  adhesions  and  the  effect 
of  ptosis  upon  intra-intestinal  movement  may  be  quite  accurately 
determined. 

The  technic  of  the  application  of  the  Roentgen  ray  to  the  diagnosis 
of  diseases  of  the  digestive  tract  is  similar  to  that  employed  in  exami- 
nation of  the  body  for  surgical  Roentgen  pathology.  It  cannot  be 
taught  in  books,  but  needs  months  of  study  in  well-appointed 
Roentgen  laboratories. 

Roentgenography  of  the  stomach,  esophagus,  and  intestine  both 
large  and  small,  shows  the  form  of  these  organs,  their  deviation  from 
normal  with  respect  to  size  and  contour;  furthermore,  their  position 
and  action  as  governed  by  muscular  contractions,  so  that  either  the 
normal  physiology  may  be  established  or  the  pathologic  diagnosis 
may  be  arrived  at.  Oftentimes  the  dividing  line  between  the  physio- 
logic and  the  pathologic  appearance  is  slight;  nevertheless  the 
Roentgen-ray  examination  of  the  .gastro-intestinal  tract  furnishes 
definite  information  which  cannot  be  acquired  with  as  much  cer- 
tainty by  any  other  method.  While  few  organic  lesions  present  an 
absolutely  pathognomonic  appearance  when  viewed  singly,  yet  a 
complete  examination  of  the  gastro-intestinal  tract  by  the  fluoro- 
scopic method,  assisted  by  manipulation  and  combined  with  the 
serial  plate  procedure,  will  rarely  miss  important  pathology. 

Spasm  in  different  portions  of  the  gastro-intestinal  tract,  especially 
with  regard  to  the  pylorus  and  the  greater  curvature  of  the  stomach, 
is  often  mistaken  for  an  organic  lesion.  Atropin  relieves  spasm 
and  should  always  be  employed  as  a  routine  measure  in  every  case 
where  spasm  is  suspected;  it  can  be  given  hypodermically  in  doses  of 
0.0006  Gm.  (y^j  grain). 

EXAMINATION  OF  THE  ESOPHAGUS. 

While  the  application  of  the  Roentgen  ray  in  the  diagnosis  of 
diseases  of  the  alimentary  tract  was  first  practiced  by  F.  H.  Williams, 
of  Boston,  Holzknecht  demonstrated  in  particular  that  an  oblique 
transillumination  of  the  esophagus  (from  the  right  posteriorly  to 
the  left  anteriorly,  or  from  the  left  posteriorly  to  the  right  ante- 
riorly)  permits  convenient  observation  of    the   entire  "esophageal 


EXAMINATION  OF  THE  ESOPHAGUS  137 

tract.  The  condition  of  the  lnincn  of  the  gullet  can  thus  he  closely 
studied  during  rest,  during  respiration,  and  during  deglutition.  The 
pharynx  and  the  upper  portion  of  the  esophagus  may  also  be  ex- 
posed to  the  Roentgen  ray,  illuminating  the  throat  in  a  transverse 
or  oblique  direction. 

Roentgen-ray  examination  of  the  esophagus  gives  most  accurate 
and  constant  findings.  In  order  to  obtain  a  constant  shadow  of  the 
esophagus,  there  must  be  an  obstruction.  Recently  the  use  of  a 
bismuth-filled  "hog  casing"  has  given  early  information  of  slight 
indentations  and  stricture.  Bismuth  suspended  in  syrup  of  acacia, 
making  a  very  thick  emulsion,  gives  perhaps  the  most  complete 
outline  of  the  esophagus,  inasmuch  as  the  syrupy  mixture  tends  to 
adhere  to  the  esophageal  walls.  The  details  of  this  method  have 
been  perfected  by  Hirsch,  of  New  York.  Besides  the  presence  of 
intrathoracic  masses,  a  roentgenogram  will  show  obstruction  due 
to  changes  in  the  walls  of  the  esophagus,  as  stricture,  benign  and 
malignant  growths,  aneurysm,  diverticulum  and  spasm.  The 
esophagospasm  may  be  due  to  ulcer,  to  carcinoma,  or  to  a  neurosis, 
as  in  cardiospasm. 

Spasm  of  the  Esophagus. — A  spastic  stricture  does  not  present  any 
absolutely  characteristic  appearance.  The  bismuth  meal  remains 
lodged  above  the  stricture,  and  in  some  cases  it  may  taper  downward 
to  a  point  at  the  end  of  the  stricture,  where  it  remains  stationary. 
If,  after  long-continued  observation,  very  little  of  the  meal  is  found 
to  have  passed  through  the  stricture,  the  lowrer  end  will  have  the 
appearance  of  long  shreds.  These  cases  are  the  grave  ones,  usually 
involving  the  lowest  portion  of  the  esophagus,  the  cardia.  When 
the  cardia  is  involved,  the  esophagus  is  quite  apt  to  take  on  the 
form  of  a  spindle  or  funnel.  In  moderately  severe  cases  the  meal 
passes  the  stricture  from  the  beginning  in  separate,  small,  long- 
drawn-out  pieces.  In  the  milder  cases,  which  are  mostly  supra- 
cardiac,  marked  dilatation  of  the  esophagus  is  usually  not  visible; 
the  meal'  is  detained  for  a  time  and  then  suddenly  passes  onward. 

Cardiospasm.— Cardiospasm  is  not  a  rare  occurrence.  The  treat- 
ment of  this  condition  will  be  quite  different  from  that  of  malignancy, 
therefore  an  accurate  diagnosis  is  indispensable.  In  addition  to  the 
aid  afforded  by  the  esophagoscope,  we  can  readily  differentiate  an 
organic  stricture  from  a  cardiospasm  by  the  roentgenogram.  In 
old  cases  the  esophagus  above  the  obstruction  may  be  dilated  to 
twice  its  normal  size.  In  cardiospasm  the  obstruction  is  funnel- 
shaped  (Plate  XI,  Fig.  1),  while  in  organic  stricture  the  lower  end  is 
round  and  knob-like  (Plate  XI,  Fig.  2).  In  cardiospasm  the  fluoro- 
scopic examination  will  usually  show  that  there  is  an  absolute 
closure  of  the  lower  end  of  the  esophagus  so  that  no  drops  of  the 
barium  mixture  pass  off  into  the  stomach.  In  malignant  obstruction 
of  the  lower  end  of  the  esophagus,  except  in  the  most  advanced 
cases,  there  will  be  found  to  be  a  minute  trickling  of  the  barium 


138  ROENTGEN-RAY  EXAMINATION 

through  the  diminished  lumen.  Another  important  point  in  the 
differential  diagnosis  is  that  after  the  spasm  has  been  observed  for 
several  moments,  if  the  esophagus  is  filled  up  with  warm  water  this 
will  cause  the  muscular  fibers  to  relax  and  the  barium  mixture  will 
rush  on  into  the  stomach.  In  many  cases  of  obstruction  the  tissues 
above  the  stricture  lose  their  tone,  and  peristalsis  fails. 

Diverticulum  of  the  Esophagus. — The  presence  of  a  diverticulum 
is  demonstrated  by  the  intensely  dark,  sharply  defined  shadow  it 
casts  (Plate  XI,  Figs.  3  and  4),  while  at  the  same  time  a  metal  sound 
introduced  beyond  it  in  the  esophagus  is  visible  upon  illumination. 
Should  a  diverticulum  be  completely  filled  with  food,  it  is  of  course 
impossible  to  fill  it  with  bismuth,  and  the  roentgenogram  will 
not  show  it.  In  doubtful  cases  examination  should  be  made  after 
vomiting  and  in  various  postures  of  the  body. 

Deep-seated  Diverticula. — These  also  may  be  demonstrated  by 
filling  with  bismuth,  and  the  demonstration  confirmed  by  intro- 
ducing the  esophageal  sound;  or  the  bismuth-filled  "hog  casing" 
may  be  used. 

Carcinoma  of  the  Esophagus. — Roentgenography  may  show  a 
narrowing  of  the  lumen  where  there  are  no  clinical  signs  of  such  a 
condition  or  any  obstruction  to  the  passage  of  sounds.  Irregular, 
jagged  contours  of  the  bismuth  shadow  point  to  the  presence  of 
carcinoma  (Plate  XII,  Figs.  1  and  2).  We  are  able,  after  filling  the 
esophagus  with  bismuth,  to  determine  in  advanced  cases  the  length 
of  the  stricture  and  the  presence  of  a  number  of  stenosed  points. 
Constant  stenosis  as  distinguished  from  spastic  stenosis  is  of  diag- 
nostic importance.  By  artificially  closing  the  lower  end  of  the 
esophagus,  the  bismuth  may  be  made  to  show  slight  irregularities 
above,  which  might  otherwise  escape  notice. 

EXAMINATION  OF  THE  STOMACH. 

In  order  to  interpret  the  visualization  of  the  stomach  it  is  neces-. 
sary  to  recognize  the  normal  stomach  and  to  be  able  to  differentiate 
reflex  from  directly  pathologic  forms.  Reflex  manifestations  are  of 
a  spastic  character  and  are  found  in  diseases  of  the  duodenum, 
appendix,  gall  bladder,  and  other  more  remote  organs.  The  hypo- 
dermic injection  of  atropin  will  often  cause  these  spasms  to  disappear 
and  is  accordingly  helpful  in  differentiating  reflex  from  direct  mani- 
festations of  disease. 

It  is  difficult  to  describe  the  appearance  of  the  normal  stomach  as 
visualized  by  the  fluoroscopic  screen.  The  reason  for  this  consists  in 
the  fact  that  the  position  of  the  stomach  varies  in  different  indi- 
viduals in  accord  with  the  bodily  habitus.  After  one  has  acquired 
experience  by  the  examination  of  a  large  number  of  individuals, 
he  is  able  to  predict  the  position  of  the  stomach  by  looking  at  the 
patient's  general  habitus.    Individuals  of  the  spare  type  with  flat 


EXAMINATION  OF  THE  STOMACH  139 

abdominal  wall  usually  possess  a  vertical  type  of  stomach.  This 
vertical  type  in  general  shows  the  form  of  a  gigantic  letter  J.  The 
most  dependent  portion  of  the  lower  curve  may  or  may  not  be  above 
the  intercrestal  line.1     (Plate  XII,  Figs.  3  and  4.) 

In  individuals  of  more  robust  physique,  with  well  developed 
muscular  abdominal  wall,  the  stomach  will  generally  be  found  to  be 
oblique.  In  those  of  plethoric  habit  with  thick  abdominal  wall,  the 
stomach  will  assume  more  the  horizontal  type.  The  exhaustive 
studies  of  Mills  have  definitely  decided  the  above  point. 

Under  the  fluoroscope  the  peristaltic  waves  of  the  stomach  are 
seen  to  be  rhythmical  in  character.  Normally  one  wave  appears 
at  a  time.  The  presence  of  two  or  more  waves  gives  evidence  of 
hypermotility  and,  if  not  due  to  an  effort  to  overcome  an  obstruction 
at  the  pylorus,  may  be  significant  of  an  irritation  which  usually  has 
its  origin  in  the  duodenum,  the  appendix,  or  the  gall  bladder.  In 
the  vertical  type  of  stomach  the  walls  of  the  stomach  are  parallel 
if  there  is  a  good  muscular  tonus.  Often  during  an  examination  this 
muscular  tonus  may  be  present  at  the  beginning  but  under  the  stress 
of  supporting  the  heavy  meal  the  muscle  fibers  relax  and  we  have 
the  appearance  of  an  hour-glass  (the  so-called  pseudo-hourglass) 
with  the  walls  of  the  middle  portion  in  apparent  contact.  In  addi- 
tion to  the  collapse  of  the  walls,  we  find  a  sagging  of  the  lower 
portion  of  the  stomach  so  that  the  lower  pole  appears  very  much 
dilated. 

In  gastric  ulcer,  only  one  peristaltic  wave  is  apparent.  This 
condition  may  often  be  differentiated  from  the  normal  by  the  pres- 
ence of  an  incisura  due  to  the  ulcer. 

Gastroptosis. — After  the  bismuth  meal  the  stomach  in  gastroptosis 
shows  as  an  elongated  tube  standing  vertically  to  the  left  of  the 
median  and  with  its  lower  border  far  below  the  intercrestal  line. 
At  its  lower  extremity  it  turns  to  the  right  with  a  sharp  curve  upward 
so  that  the  lesser  curvature  shows  an  acute  angle  at  the  turning  point; 
this  is  called  a  water-trap  stomach  (Plate  XIII,  Fig.  1).  In  some 
cases  of  gastroptosis  the  stomach  may  extend  almost  to  the  sym- 
physis (Plate  XIII,  Fig.  2);  the  pylorus  is  always  lower  than 
normal.  Many  individuals  will  be  found  wiio  show  a  rather  marked 
gastroptosis  without  presenting  clinical  evidence.  The  important 
point  to  determine  in  these  cases  is  whether  the  motor  power  of  the 
stomach  is  competent,  for  if  the  musculature  of  the  stomach  pos- 
sesseslthe  necessary  tone  and  strength  to  cause  the  stomach  to 
emptyLin  a  normal  period  of  time,  there  will  be  no  clinical  symptoms. 

1  The  earlier  method  of  comparing  the  position  of  the  stomach  with  the  um- 
bilicus had  the  disadvantage  of  an  inconstant  factor,  namely,  the  varying  position 
of  the  umbilicus.  It  is  accordingly  more  convenient  to  record  the  position  of  the 
dependent  portion  of  the  stomach  by  referring  its  relative  position  to  a  line  drawn 
from  the  crest  of  one  ilium  to  the  crest  of  the  other,  an  imaginary  landmark  which 
is  known  as  the  intercrestal  line. 


140  ROENTGEN-RAY  EXAMINATION 

Tonus.- — Gastric  tonus  is  the  resiliency  or  continuous  contractility 
of  the  living  stomach  which  enables  it  to  hold  its  contents  firmly 
and  to  keep  its  own  normal  shape.  The  tonus  of  the  stomach  is 
demonstrated  by  the  strength  with  which  the  organ  clutches  its 
contents.  In  a  condition  of  normal  gastric  tonus  a  small  quantity 
of  fluid  will  almost  completely  fill  the  stomach  (Plate  XIII,  Fig.  3),  so 
that  the  upper  level  of  the  fluid  is  even  with  the  diaphragm  and  the 
air  bubble  is  in  the  fundus  (magenblase)i;  the  walls  of  the  stomach 
are  vertical  and  parallel.  Loss  of  tonus  is  accurately  shown  by 
roentgenography. 

Motility.- — The  motor  function  of  the  normal  stomach  is  measured 
by  observing  peristalsis  and  determining  the  time  required  for 
expulsion  of  the  gastric  contents.  Peristalsis  begins  immediately 
after  the  ingestion  of  the  bismuth  meal,  in  the  form  of  waves  originat- 
ing approximately  in  the  middle  of  the  body  of  the  stomach  and  pro- 
gressing toward  the  pylorus.  They  are  shallow  at  first,  but  become 
constantly  deeper.  If  the  peristaltic  waves  are  slow  in  appearing 
they  may  often  be  stimulated  and  consequently  visualized  by  ener- 
getic manipulation  of  the  lower  pole  of  the  stomach.  The  time 
of  expulsion  is  determined  by  roentgenologically  illuminating  the 
stomach  at  regular  intervals,  beginning  with  the  second  hour  after 
ingestion  of  a  bismuth  test  meal  and  continuing  until  the  last  rem- 
nant of  bismuth  has  disappeared.  The  normal  time  of  expulsion 
is  between  four  and  six  hours.  Failure  of  the  stomach  to  empty 
itself  of  the  entire  bismuth  meal  in  four  to  six  hours  is  an  indication 
of  a  pathologic  process,  but  on  account  of  the  fact  that  the  mechan- 
ism of  the  stomach  is  oftentimes  influenced  by  extraneous  impres- 
sions, as  fright,  the  observation  should  be  repeated  before  the  final 
conclusion  is  arrived  at. 

Atony. — A  lowering  of  the  tonus  of  the  stomach  is  shown  by 
lessened  contraction  around  its  contents,  and  by  increased  expansi- 
bility, with  markedly  flaccid  walls.  The  bismuth  test  meal  fills 
only  the  lower  half  of  the  stomach,  its  upper  level  being  far  below 
the  diaphragm,  perhaps  only  slightly  above  the  umbilicus.  Above 
it  there  is  a  large  club-shaped  air  bubble  (Plate  XIII,  Fig.  4).  The 
stomach  is  narrowest  at  the  border-line  between  air  bubble  and 
bismuth. 

Dilatation. — In  a  markedly  dilated  stomach  (benign  stenosis  of 
the  pylorus)  the  bismuth  meal  fills  merely  the  lowest  portion  of  the 
stomach  in  the  form  of  a  broad  crescent -shaped  shadow,  situated 
below  the  umbilicus  (Plate  XIV,  Fig.  2).  The  form  of  the  shadow 
is  fairly  horizontal;  at  the  same  time  it  extends  far  into  the  right 
half  of  the  body.  The  pars  pylorica  is  usually  not  well  differentiated. 
Above  the  bismuth  meal  will  be  found  the  fluid  and  the  stagnating 
food  remnants  which  are  always  present  in  an  ectatic  stomach. 
The  presence  of  a  layer  of  fluid  over  the  bismuth  meal  can  be  demon- 
strated by  the  administration  of  floating  bismuth  capsules.    The 


EXAMINATION  OF  THE  STOMACH  I  II 

stomach  increases  in  size  if  more  he  added  to  its  contents.  Visible 
remnants  of  bismuth  twenty-four  hours  after  the  bismuth  test  meal 
are  proof  usually  of  an  organic  lesion  at  the  pylorus  or  more  fre- 
quently a  lesion  in  the  first  portion  of  the  duodenum. 

An  extraordinarily  intensified  and  increased  peristalsis  can  be 
observed  on  the  screen.  This  is  succeeded  by  a  flaccid  condition 
of  the  stomach  walls  due  to  a  tiring  of  the  muscle  fibers.  A  reversed 
peristalsis,  flat  waves  from  right  to  left,  has  also  been  observed. 

Gastric  Ulcer. — A  simple  non-complicated  ulcer  cannot  with 
certainty  be  demonstrated  by  means  of  the  Roentgen  ray.  An 
ulcer  causes  a  localized  tonic  spasm  of  the  circular  muscle  fibers, 
inducing  an  incisura  or  deep  notch  on  the  curvature  opposite.  To 
visualize  this,  roentgenoscopy  palpation  may  be  necessary.  The 
Roentgen  fluoroscope  may  show  a  stoppage  of  the  peristaltic  wave 
at  the  seat  of  the  ulcer.  Hypomotility  with  six-hour  residue  is 
suggestive  of  ulcer.  If  the  peristaltic  waves  are  seen  to  traverse 
the  lower  pole  of  the  stomach,  causing  indentations  on  the  greater 
curvature  and  not  on  the  lesser,  ulcer  may  be  suspected. 

We  can  classify  the  findings  in  gastric  ulcer  under  the  two  general 
headings  of  direct  and  indirect,  the  direct  being  a  demonstration 
of  a  definite  change  resulting  from  the  ulceration,  and  the  indirect 
the  disturbances  in  function.  The  most  common  direct  findings 
are  the  bismuth  fleck  representing  the  ulcer  crater,  the  filling  defect 
in  the  gastric  outline,  and  the  organic  deformities.  The  indirect 
findings  are  spastic  manifestations,  abnormalities  in  peristaltic 
waves,  disturbed  motility,  unusual  filling  of  the  duodenum,  and 
pressure  pain  points. 

Callous  Ulcer. — If  an  induration  of  connective  tissue  occurs  in 
the  vicinity  of  a  chronic  ulcer,  so  that  the  ulcer  presents  a  crater -like 
opening,  this  crater  can  be  filled  up  with  bismuth  and  may  then  be 
seen  as  a  small  diverticular  continuation  of  the  shadow  of  the  stom- 
ach. There  is  no  air  bubble  in  this  ulcer  cavity  filled  with  bismuth. 
Induration  of  an  ulcer  of  the  stomach  induces  irregularities  or 
absence  of  the  peristaltic  waves.  Gastric  ulcer,  wherever  located, 
tends  to  induce  retention  of  the  stomach  contents.  The  presence 
of  a  callous  ulcer  may  also  be  assumed  if  a  persistent  hour-glass 
stomach  can  be  demonstrated.     (Plate  XV,  Fig.  2.) 

Perforating  Ulcer. — A  callous  ulcer  that  is  adherent  to  an  adjacent 
organ  may  burrow  deeply  into  it.  The  most  frequent  adhesions  of 
the  stomach  are  with  the  pancreas  and  the  liver.  Pockets  of  varying 
sizes  are  thus  formed.  It  is  a  simple  matter  to  demonstrate  with  the 
Roentgen  ray  the  presence  of  such  pockets.  The  bismuth  meal 
partly  fills  the  pocket,  which  communicates  with  the  stomach 
through  a  narrower  passage,  and  the  cavity  then  appears  as  a  diver- 
ticular attachment  of  the  stomach  shadows  This  diverticulum  is 
partly  filled  with  bismuth  (Plate  XIV,  Figs.  3  and  4)  over  which 
there  is  an  air  bubble  (Haudek's  niche).    The  bismuth  in  the  pocket 


142  ROENTGEN-RAY  EXAMINATION 

sometimes  appears  entirely  separated  from  the  stomach  shadow, 
without  any  visible  connection  with  it.  Characteristic  of  perforat- 
ing ulcer  is  the  fact  that  the  shadow  of  the  bismuth-filled  pocket 
remains  after  the  stomach  is  emptied  (Plate  XV,  Fig.  1). 

Hour-glass  Stomach.- — An  hour-glass  stomach  is  either  functional, 
due  to  local  spastic  contraction  (intermittent  hour-glass  stomach), 
or  organic,  due  to  cicatrices  of  ulcers,  callous  ulcers,  perigastritis, 
or  carcinomata  (persistent  hour-glass  stomach).  But  mixed  forms 
also  may  occur.  In  the  persistent  organic  hour-glass  stomach 
(Plate  XV,  Fig.  2),  after  the  bismuth  test  meal,  only  the  cardiac 
half  of  the  stomach  appears  filled.  The  filling  of  the  pyloric  half 
may  take  place  very  gradually.  If  the  pyloric  portion  fills  imme  • 
diately  after  the  meal,  the  case  is  not  one  of  organic  hour-glass 
stomach,  but  may  be  the  spastic  or  mixed  form,  which  is  not  a  rare 
occurrence  in  ulcer.    Atropin  may  be  useful  in  the  differentiation. 

Carcinoma.- — The  chief  and  frequently  the  only  finding  in  gastric 
carcinoma  is  a  filling  defect.  Depending  upon  the  location,  there 
will  be  disturbances  in  motility.  With  a  carcinoma  involving  the 
cardiac  end  of  the  stomach,  there  is  usually  early  emptying.  In 
carcinoma  involving  the  middle  pole  the  emptying  time  is  frequently 
not  disturbed;  and  in  carcinoma  of  the  pylorus  there  is  usually 
obstruction.  Besides  establishing  the  diagnosis  of  carcinoma,  the 
Roentgen  ray  has  the  additional  value  of  demonstrating  the  exact 
location  of  the  lesion  and  determines  the  decision  as  to  whether  the 
case  presents  operative  possibilities. 

If  the  bismuth  shadow  shows  fixed  irregularities  it  suggests  circum- 
scribed carcinoma  which  projects  tumor-like  into  the  stomach  cavity. 
This  filling  defect  produces  an  irregularity  of  contour  and  narrow- 
ing of  the  gastric  lumen.  Non-projecting  carcinomata  which  infil- 
trate the  wall  of  the  stomach  exhibit  these  openings  in  the  bismuth 
shadow  to  a  much  less  degree,  but  they  display  a  fairly  strong  wall, 
absence  of  peristalsis,  and  an  area  of  immobility.  (Plate  XIV, 
Fig.  1.)  In  cases  of  thickening  of  the  stomach  wall  a  marked 
decrease  of  the  lumen  is  observed.  The  most  diversified  roentgeno- 
grams present  themselves,  according  to  the  seat,  the  extent,  and 
the  diffuse  or  circumscribed  growth  of  the  carcinoma.  (Plate  XV, 
Figs.  3  and  4.)  It  should  be  borne  in  mind,  however,  that  an 
extragastric  tumor  or  cyst  which  compresses  the  stomach  may 
occasionally  simulate  a  carcinoma  of  the  stomach  in  the  roentgeno- 
gram. Extra-gastric  pressure,  however,  usually  presents  a  smooth 
outline  which  is  different  from  the  nodular,  irregular  outline  of 
carcinoma. 

Pyloric  Obstruction. — When  the  shadow  near  the  pylorus  is  round 
and  blunt  and  no  bismuth  passes  through  into  the  duodenum,  a 
pyloric  obstruction  is  present.  (Plate  XVI,  Fig.  1.)  Pylorospasm 
will  simulate  this  condition,  and  serial  roentgenograms  may  be 
necessary  for  differentiation.    Pylorospasm  is  a  constant  accom- 


EXAMINATION  OF  THE  INTESTINE  143 

paniment  of  pyloric  and  duodenal  ulcer.  This  spasm  may  usually 
be  relaxed  by  the  administration  of  belladonna  or  atropin.  Delay 
in  emptying  of  the  stomach,  associated  with  dilatation,  indicates 
an  obstruction  of  the  pylorus. 

The  period  of  expulsion  of  the  stomach  contents  is  materially 
shortened  by  external  application  of  heat.  This  fact  is  important 
in  Roentgen  differentiation  of  pylorospasm  from  organic  stenosis  of 
the  pylorus.  It  explains  also  the  relief  of  pain  in  the  stomach  by 
local  heat  which  relaxes  the  spasm  of  the  pylorus. 

The  interpretation  of  the  findings  in  pylorospasm  and  gastric 
retention  should  not  be  made  without  carefully  considering  the 
possibility  of  these  findings  being  the  result  of  a  gastric  manifesta- 
tion of  tabes.  Not  infrequently  syphilis  is  the  etiologic  factor  in 
pylorospasm  and  retention.  The  question  of  organic  deformities 
of  the  stomach  due  to  syphilis  is  of  great  importance.  Undoubtedly 
a  number  of  cases  presenting  a  tumor  of  the  stomach  have  been 
diagnosed  as  carcinoma  when  in  reality  the  deformities  were  the 
result  of  syphilis.  The  roentgenologist  should  always  suggest  the 
necessity  of  differentiating  between  carcinoma  and  syphilis  by  other 
methods  of  examination. 

EXAMINATION   OF  THE  INTESTINE. 

Roentgen-ray  examination  of  the  intestine  is  made  by  means  of 
either  the  bismuth  test  meal  or  the  barium  sulphate  enema.  It  is 
of  the  greatest  importance  that  the  intestine  be  previously  evacuated 
by  laxatives  and  by  a  cleansing  enema.  The  administration  of  the 
laxatives  should  be  so  timed,  however,  that  the  peristaltic  tone  will 
not  be  affected  by  them  when  the  Roentgen-ray  examination  is 
made. 

Roentgen-ray  examination  accomplishes  least  in  the  diagnosis  of 
conditions  in  the  small  intestine,  in  which  only  the  bismuth  test 
meal  must  be  used.  The  bismuth  rapidly  spreads  over  a  very  large 
surface  and  casts  a  characteristic  shadow  by  which  the  duodenum, 
jejunum  and  ileum  can  be  differentiated.  Characteristic  of  stenosis 
of  the  small  intestine  is  the  occurrence  of  a  double  level  of  the  liquid 
bismuth-chyme.  But  if  such  roentgenograms  are  produced,  distinct 
clinical  signs  of  stenosis  are  already  present. 

Duodenal  Ulcer. — Recognition  of  the  first  ascending  portion  of  the 
duodenum  is  all-important  in  the  roentgenograph^  diagnosis  of 
duodenal  ulcer.  The  normal  filling  of  the  bulbus  duodeni  with  the 
bismuth  mixture  has  been  called  the  duodenal  cap,  from  its  likeness 
to  a  bishop's  cap  (Plate  XVI,  Fig.  2.)  The  diagnosis  of  duodenal 
ulcer  by  roentgenography  is  based  on  a  constant  deformity  of  this 
cap  (Plate  XVI,  Figs.  3  and  4),  caused  by  induration  or  cicatricial 
contraction  surrounding  the  ulcer,  or  by  spasm  associated  with  a 
small  ulcer.    Several  roentgenograms  are  necessary  in  order  to 


144  ROENTGEN-BAY  EXAMINATION 

show  the  continuous  presence  of  this  deformity,  for  occasionally 
spasm  of  the  cap  occurs  in  vagotonia  (see  page  388).  This  latter 
condition  can  be  completely  relieved  by  the  administration  of 
atropin  or  extract  of  belladonna.  It  has  been  found  that  in  duodenal 
ulcer  the  position  or  form  of  the  stomach  is  not  normal;  there  is 
either  gastroptosis,  or  the  transverse  diameter  of  the  stomach  is 
enlarged.  This  latter  condition  is  due  to  ultradextroposition  of 
the  pylorus,  probably  caused  by  adhesions  between  it  and  the  gall 
bladder.  Gastric  peristalsis  is  very  active  in  ulcer  of  the  duodenum 
and  is  usually  fairly  characteristic.  The  waves  are  multiple  and 
usually  quite  deep,  indicating  marked  efforts  in  the  propulsion  of  the 
stomach  contents.  The  musculature  of  the  stomach  may  become 
tired  and  the  period  of  hyperperistalsis  may  be  succeeded  by  a 
period  of  rest.  At  the  same  time  the  normal  fissure  between  the 
antrum  pylori  and  the  duodenum  disappears  temporarily.  Toward 
the  close  of  the  stomach-emptying  process  a  protracted  gastric 
stagnation  often  takes  place,  coincident  with  the  occurrence  of 
pain  and  spasm.  Six  hours  after  taking  the  test  meal,  when  the 
stomach  should  be  empty,  remnants  of  bismuth  can  be  demon- 
strated in  it.  In  cases  of  callous  duodenal  ulcer  which  has  perfor- 
ated the  wall,  we  find  a  niche,  with  retention  of  bismuth;  sometimes 
a  small  air  bubble  is  visible  in  the  niche  over  the  bismuth  remnant 
(Haudek's  niche) ;  a  specially  characteristic  indication  of  perforating 
duodenal  ulcer  is  the  apparent  separation  of  the  bismuth  remnant 
from  the  shadows  of  stomach  and  duodenum  and  its  continuance 
after  the  stomach  is  entirely  empty. 

Ileal  Stasis. — Normally  the  opaque  meal  will  have  passed  into  the 
colon  in  twelve  hours.  Any  residue  after  this  time  should  be 
classified  as  due  to  ileal  stasis.  The  importance  of  ileal  stasis  as  a 
factor  in  gastric  symptoms  is  second  only  to  that  of  the  appendix. 
The  causes  of  ileal  stasis,  as  determined  by  the  Roentgen  method  of 
examination,  are:  adhesions  and  kinking,  spasm  of  the  ileocecal 
sphincter,  and  incompetency  of  the  ileocecal  valve.  Under  the  head 
of  adhesions  should,  of  course,  come  the  atypical  mesenteric  bands 
known  as  Jackson's  membrane  (see  page  561).  Incompetency  of 
the  ileocecal  valve  is  most  often  demonstrated  by  means  of  the 
barium  sulphate  enema;  but  at  times,  by  frequent  observations  of  a 
given  bismuth  test  meal,  it  can  be  definitely  shown  that  the  cecal 
contents  have  been  regurgitated  into  the  terminal  ileum.  The 
importance  of  incompetency  of  the  ileocecal  valve  has  been  over- 
estimated. Observers  of  wide  experience  state  that  in  fully  50  per 
cent,  of  the  cases  given  a  barium  enema  incompetency  is  shown. 
(Plate  XIX,  Fig.  2.) 

Colon. — The  Roentgen-ray  technic  is  exceedingly  valuable  in  ex- 
amination of  the  colon.  The  normal  state  of  the  colon,  in  particular, 
has  been  largely  elucidated  by  it.     (Plate  XVII,  Fig.  4.) 


PLATE  XI 


Fig.  1. — Cardiospasm.  The  arrows  point  to  the  lower  end  of  the  esophagus  closed  by 
spasm.  Above  is  seen  the  enormously  dilated  lumen  of  the  lower  esophagus.  The  clinical 
history  extended  over  a  period  of  several  years.  The  diagnosis  of  cardiospasm  was  not  made 
before  the  Roentgen  examination.  The  patient  was  symptomatically  relieved  by  dilatation 
with  the  water-bag  dilator.     (P.  M.  Hickey  and  W.  A.  Evans.) 

Fig.  2. — Carcinoma  of  the  Cardia.  A,  carcinomatous  obstruction  at  lower  portion  of 
esophagus;  B,  slightly  dilated  esophagus  above.     (P.  M.  Hickey.) 


Fig.  3. — Diverticulum  of  the  Upper  Esophagus.  The  barium  is  seen  faintly  outlined 
at  the  laryngo-pharynx.  The  large  rounded  shadow  is  the  visualized  diverticulum  with  a 
small  and  a  large  lobe.  The  barium  mixture  has  overflowed  and  is  escaping  into  the  esophagus 
below.     (P.  M.  Hickey  and  W.  A.  Evans.) 


Fig.  4. — Large  Diverticulum.     Wide  dilatation  of  the  sac. 
and  finally  died  of  inanition.      (P.  M.  Hickey.) 


Patient  refused  operation 


PLATE  XII 


FIG.   2 


Fig.  1. — Carcinoma  of  Middle  Third  of  the  Esophagus.  A,  slight  dilatation  of  the 
esophagus  above  the  constriction;  B,  irregular  and  contracted  appearance  of  the  bismuth 
column,  due  to  the  encroachment  of  the  carcinomatous  mass  upon  the  lumen  of  the  esophagus. 
(P.  M.  Hickey.) 

Fig.  2. — Carcinoma  of  the  Lower  Third  of  the  Esophagus.  Note  the  irregular  out- 
line of  the  lower  portion  of  the  visualized  esophagus  and  the  marked  dilatation  above.  The 
arrows  point  to  the  irregularity  of  the  barium  outline  produced  by  the  nodular  condition  of 
the  new  growth  of  the  esophagus.     (P.  M.  Hickey  and  W.  A.  Evans.) 


FIG.   3 


FIG.   4 


Fig.  3. — Normal  Horn-shaped  Stomach  (Cow-horn)  as  found  in  Persons  of  the 
Robust  Type.     A,  corpus;  B,  pars  pylorica;  C,  pylorus;  D,  duodenal  cap.     (P.  M.  Hickey.) 

Fig.  4. — Normal  Fish-hook  Stomach  as  found  in  Persons  of  the  Asthenic  Type. 
A,  air  bubble  in  fundus;  B,  umbilicus;  C,  pylorus.     (P.  M.  Hickey.) 


PLATE   XIII 


*        M 

^  *kjB    v 

Jh 

L 

hjk 

C     ,\      ' 

Fig.  1. — Gastroftosis  (Water-trap  Stomach).     A,  air  bubble  in  fundus;  B,  rugae;  C, 
lower  border  of  stomach;  D,  pylorus.      (P.  M.  Hickey.) 

Fig.  2. — Marked  Gastroftosis.     Stomach  near  Symphysis.     A,  elongated  air  bubble 
in  fundus;  B,  ruga?;  C,  lower  border  of  stomach.     (P.  M.  Hickey.) 


FIO.  8 


Fig.  3. — Normal  Tonus.  A,  air  bubble  in  fundus;  B  and  C,  parallel  walls  of  the  stomach; 
D  and  E,  peristaltic  waves.     (P.  M.  Hickey.) 

Fig.  4. — Atony.  A,  conspicuous  air  bubble  in  fundus;  B,  puckering  of  the  walls  of  the 
stomach  below  .4.;  C,  flaccid  condition  of  body  of  stomach.  Note  the  transverse  colon  (£)) 
outlined  by  contained  air  below  the  position  of  the  stomach.      (P.  M.  Hickey.) 


PLATE  XIV 

FIG.   1  FIG.   2 


Fig.  1. — Carcinoma  of  the  Stomach.  A,  fundus  of  the  stomach;  B,  deep  filling  defect 
due  to  the  projection  of  the  neoplasm  into  the  stomach;  C,  drawing  in  of  the  stomach  due  to 
cicatrization  of  an  old  ulcer;  D,  pylorus;  E,  dilated  duodenum.     (P.  M.  Hickey.) 

Fig.  2. — Simple  Dilatation  of  the  Stomach.  Xo  clinical  history  except  continual  over- 
eating.    (P.  M.  Hickey.) 


FIG.  3 


Figs.  3  and  4. — Perforating  Ulcer  of  the  Stomach.  Four  serial  plates  illustrating 
the  constancy  of  the  lesion,  despite  the  change  in  the  pyloric  contour  due  to  the  peristaltic 
waves.  Duodenum  distorted  by  adhesions.  Operation — excision  of  ulcer  and  gastroenteros- 
tomy.    (P.  M.  Hickey  and  W.  A.  Evans.) 


PLATE   XV 


FIG.   1 


FIG.   2 


I 


Fig.  1. — Ulcer  of  the  Stomach  (Perforating).  A,  air  bubble  in  fundus;  B  and  C, 
indentation  due  to  "saddle"  ulcer;  D,  pocket  due  to  perforation,  with  the  walls  adherent 
to  liver;  E,  narrow  isthmus  connecting  D  with  lower  portion  of  stomach,  F.  Verified  by 
operation.     (P.  M.  Hickey.) 

Fig.  2. — Hour-glass  Stomach.  .4,  upper  half  of  stomach  connected  by  B,  narrow 
isthmus  of  bismuth  resulting  from  contraction  of  middle  of  stomach  due  to  ulcer,  with  cicatri- 
cial band;  C,  lower  pole  of  stomach,  the  pyloric  portion  of  which  is  completely  filled  while  the 
upper  part  shows  the  bismuth  gradually  trickling  down  through  isthmus,  B.     (P.  M.  Hickey.) 


FIG.  S 


Fig.  3. — Carcinoma  of  the  Stomach.  Infiltration  of  the  lower  pole  of  the  stomach,  with 
slight  and  very  irregular  filling.  Operation.  This  should  not  be  mistaken  for  filling  defect 
due  to  pressure.  This  case  was  operative  because  the  growth  was  not  so  extensive  as  to  pre- 
clude gastroenterostomy.     Compare  with  Plate  XVI,  Fig.  1.      (P.  M.  Hickey.) 

Fig.  4. — Carcinoma  of  the  Stomach  (Advanced).  On  account  of  the  neoplastic  mass 
the  bismuth  does  not  enter  the  lower  third  of  the  stomach.     Inoperable.     (P.  M.  Hickey.) 


PLATE   XVI 

FIG.    1  FIG.   2 


Fig.  1. — Carcinoma  of  the  Stomach.  Extensive  infiltration  extending  from  the  pylorus 
along  the  lower  border,  with  slight  chance  for  escape  of  bismuth  along  the  lesser  curvature,  A. 
(P.  M.  Hickey.) 

Fig.  2. — Normal  Duodenal  Cap.  .4,  pylorus;  B,  duodenal  cap— bulbus  duodeni.  (P. 
M.  Hickey.) 


FIG.  S 


YIG.  3. — TJlceb  of  the  Duodenum  (Deformed  Cap)  .  The  incomplete  filling  of  the  upper 
portion  of  the  duodenal  cap  was  a  constant  finding  on  a  series  of  eight  plates.  Operation. 
(P.  M.  Hickey.) 

Fig.  4.— Chronic  Duodenal  Ulcer.  Dilated  stomach  due  to  obstruction  at  pylorus 
(A),  which  was  found  at  operation  to  be  involved  in  a  dense  mass  of  adhesions,  with  chronic 
ulcer  of  the  duodenum.     (P.  M.  Hickey.) 


PLATE  XVII 


FIG.   2 


Fig.   1. — Enormous  Dilatation  of  Duodenal  Cap.     A,   pylorus;  B,   duodenal   cap. 
Constant  finding  on  series  of  twelve  plates.     (P.  M.  Hickey.) 

Fig.  2. — Dilated  Duodenum.     Dilatation  of  second  portion  of  duodenum  due  to  band 
of  probable  embryonic  origin.     Operation.     (P.  M.  Hickey.) 


FIG.   3 


FIG.  4 


Fig.  3. — Carcinoma  Small  Intestine.  Marked  dilatation  of  the  small  bowel.  Visu- 
alized with  the  barium  content  through  the  distention  with  air.  The  dilatation  was  due 
to  the  carcinoma  causing  the  obstruction.  The  striae  seen  in  the  dilated  small  bowel  are 
quite  characteristic  of  this  condition.     (P.  M.  Hickey  and  W.  A.  Evans.) 

Fig.  4. — Normal  Colon.     (P.   M.   Hickey.) 


PLATE  XVIII 


FIG.    1 


FIG.   2 


Fig.  1. — Coloptosis.  A,  umbilicus;  B,  cecum;  C,  air-filled  hepatic  flexure;  D,  air-filled 
splenic  flexure;  E,  transverse  colon;  F,  sigmoid.     (P.  M.  Hickey.) 

Fig.  2.— Acute  Splenic  Flexure.  A,  cecum;  B,  partly  air-filled  hepatic  flexure;  C, 
splenic  flexure  with  left  portion  of  transverse  colon  coming  up  and  forming  an  acute  angle 
with  descending  colon,  D.     (P.  M.  Hickey.) 


FIG.  A 


Fig.  3. — Acute  Hepatic  Flexure.  A,  cecum;  B,  hepatic  flexure,  the  right  half  of  the 
transverse  colon  forming  an  acute  angle  with  the  ascending  colon;  C,  sigmoid;  D,  dilated 
ampulla  of  the  rectum.      (P.  M.  Hickey.) 

Fig.  4. — Normal  Cecum.  A,  cecum;  B,  splenic  flexure;  C,  transverse  colon;  D,  hepatic 
flexure;  E,  descending  colon;  F,  sigmoid;  G,  rectal  valve.     (P.  M.  Hickey.) 


PLATE   XIX 


FIG.    1 


FIG.   2 


Fig.   1. — Prolapsed  Cecum.     .4,  enormously  dilated  cecum  extending  well  down  into 
the  pelvis;  B,  hepatic  flexure;  C,  splenic  flexure;  D,  pylorus.     (P.  M.  Hickey.) 

Fig.  2. — Insuffiency  of  the  Ileocecal  Valve.     A,  cecum;  B,  ileum  filled  by  escape 
of  the  bismuth  clysma;  C,  normal  sigmoid.     (P.  M.  Hickey.) 


FIG.  3 


FIG.  4 


1 

.     ■ 

'-tf& 

Fig.  3. — -Appendix  Visualized  through  Retention  of  Barium  Contents  as  seen 
Forty-eight  Hours  after  the  Ingestion  of  the  Opaque  Meal.  The  irregular  filling  of 
the  appendix  is  suggestive  of  partial  stenosis.     (P.  M.  Hickey  and  W.  A.  Evans.) 

Fig.  4. — Adherent  Sigmoid.  A,  cecum;  B,  hepatic  flexure;  C,  right  half  of  the  trans- 
verse colon  descending  abruptly;  D,  left  lateral  half  of  the  transverse  colon  abruptly  ascending; 
E,  descending  colon;  F,  first  limb  of  the  sigmoid  held  to  the  right  of  the  median  line  by  adhe- 
sions; G,  second  limb  of  sigmoid.     (P.  M.  Hickey.) 


PLATE  XX 


FIG.   2 


Fig.  1. — Carcinoma  of  the  Hepatic  Flexure.  Palpable  mass  on  the  right  side. 
Patient  fifty-five  years  of  age.  Constant  filling  defect  in  the  hepatic  flexure  as  outlined  by 
barium  per  mouth  and  by  barium  enema.     Confirmed  by  operation.    (P.  M.  Hickey  and  W.  A. 

Evans.) 

Fig.  2. — Spastic  Constipation.  A,  cecum;  B,  hepatic  flexure;  C,  transverse  colon;  D, 
descending  colon  third  day  after  ingestion  of  bismuth.     Patient  relieved  by  atropin.     (P.  M. 

Hickey.) 


FIG.  3 


FIG.   4 


Fig.  3. Htpertrophied  Rectal  Valve.  J.,  deep  indentation  in  rectum  due  to  hyper- 
trophy of  first  rectal  valve.     (P.  M.  Hickey.) 

FIG.  4. Dtschezia  (Rectal  Constipation).     A,  dilated  ampulla  of  rectum;  B,  hyper- 

trophied  rectal  valve;  C,  sigmoid.     (P.  M.  Hickey.) 


PLATE   XXI 


Fig.  1. — Hirschsprung's  Disease.  A,  cecum  partly  compressed  by  sigmoid;  B,  hepatic 
flexure;  C,  transverse  colon;  D,  splenic  flexure;  E,  descending  colon;  F,  sigmoid;  G,  ampulla 
of  rectum.  Patient  referred  for  examination  by  the  Juvenile  Court,  where  he  had  been 
reported  as  an  incorrigible.     (P.   M.  Hickey.) 

Fig.  2. — Periduodenal  Adhesions.  Indistinct  and  incomplete  filling  of  the  first  portion 
of  the  duodenum,  due  to  extraduodenal  adhesions.     (P.  M.  Hickey.) 


FIG.  3 


FIG.  4 


Fig.  3. — Gallstones.     Verified  by  operation.     (P.  M.  Hickey.) 

Fig.  4. — A  gallstone  of  such  size  that  it  was  seen  on  the  preliminary  fluoroscopic  exami- 
nation.    (P.  M.  Hickey  and  W.  A.  Evans.) 


PLATE  XXII 

FIG.   1  FIG.   2 


Fig.  1. — -Multiple  Diverticula.  Patient  complained  of  lower  left  quadrant  pain  for 
several  years.  On  the  fifth  day  after  the  ingestion  of  the  barium  meal  the  diverticula  were 
quite  sharply  shown  in  the  area  where  the  patient  complained  of  pain.  The  visualized  appen- 
dix can  also  be  made  out  in  the  lower  right  quadrant,  but  was  found  to  be  freely  movable 
and  not  painful  on  pressure.     (P.  M.  Hickey  and  W.  A.  Evans.) 

Fig.  2. — Carcinoma  of  the  Rectum.  Diminished  lumen  of  the  ampulla  of  the  rectum 
as  visualized  by  barium  enema.  Above  is  to  be  seen  the  outline  of  the  sigmoid.  (P.  M. 
Hickey  and  W.  A.  Evans.) 


FIG.  3 


Fig.  3. — Syphilitic  Stenosis  of  the  Rectum.     (P.  M.  Hickey  and  W.  A.  Evans.) 


Fig.  4. — Salivary  Calculi. 
duct.     (P.  M.  Hickey.) 


A,  mylohyoid  groove;  B,  calculus  embedded  in  salivary 


EXAMINATION  OF  THE  INTESTINE  I  I". 

Normal  Motility. — The  first  signs  of  shadow  formation  are  found 
in  the  ileocecal  region  about  four  and  one-half  hours  after  ingestion 
of  the  bismuth  test  meal.  The  hepatic  flexure  is  reached  in  five  to 
eight  hours;  the  splenic  flexure  in  seven  to  fourteen  hours.  The 
final  discharge  of  the  bismuth  through  the  anus  depends  essentially 
upon  the  time  of  defecation;  at  the  earliest  it  takes  place  seven  to 
eight  hours  after  ingestion  of  the  test  meal.  It  is  of  importance  to 
know  that  remnants  of  bismuth  may  normally  remain  in  the  cecum 
and  in  the  ascending  colon,  and  also  in  the  flexures,  for  some  length 
of  time  after  the  bulk  of  the  meal  has  passed  through  these  parts. 

In  the  cecum  and  the  ascending  colon,  where  the  opaque  mass  is 
of  a  relatively  fluid  consistency,  the  shadow  is  comparatively  diffuse 
and  indistinct.  In  the  transverse  colon  and  the  descending  colon  there 
appear,  as  a  result  of  scybala  formation,  sharply  defined  spot-like 
shadows,  so  that,  in  keeping  with  the  haustral  sections,  a  rosary-like 
picture  of  these  intestinal  parts  is  formed.  (Plate  XVIII,  Fig.  4.) 
The  cecum  under  normal  conditions  is  situated  in  the  right  iliac 
fossa  and  continues  upward,  without  any  sharply  defined  demarca- 
tion, into  the  ascending  colon.  (Plate  XVIII,  Fig.  4.)  The  hepatic 
flexure  almost  never  extends  higher  than  the  lower  border  of  the 
right  costal  arch.  From  here  the  transverse  colon  rises  in  a  varying 
bow-line  to  the  splenic  flexure,  which  regularly  lies  higher  than  the 
hepatic  flexure  and  often  touches  the  left  diaphragm.  A  more  or 
less  considerable  accumulation  of  air  is  generally  observed  in  the 
flexures,  so  that  it  is  not  always  easy  to  distinguish  between  a  good- 
sized  air  bubble  in  the  splenic  flexure  and  the  air  bubble  in  the 
stomach.  The  descending  colon  extends  vertically  downward  to 
the  left  iliac  fossa.  The  sigmoid  flexure  shows  a  greatly  varying 
loop  formation. 

In  about  50  per  cent,  of  patients  examined  by  the  Roentgen  ray 
it  is  possible  to  visualize  the  vermiform  appendix.  (Plate  XIX, 
Fig.  3.) 

Position. — An  exact  determination  of  the  normal  position  of  the 
colon  is  important  if  effective  massage  of  this  portion  of  the  intestinal 
canal  is  to  be  undertaken — for  stimulation  of  peristalsis  by  massage 
can  be  accomplished  only  when  the  massage  is  applied  to  the  colon 
in  the  direction  of  its  course.     (Plate  XVII,  Fig.  4.) 

The  colon  is  best  studied  after  the  barium  sulphate  enema.  It  is 
thus  possible  to  demonstrate  position  anomalies,  formation  of  loops, 
dilatation  and  stenosis  of  the  lumen,  kinking,  adhesions,  spasms, 
and  palpable  tumors  referable  to  the  intestine.  When  the  lumen  is 
constricted  it  is  possible  to  distinguish  with  some  degree  of  certainty 
intestinal  tumors,  spasms,  and  constrictions  due  to  adhesions. 
'When  adhesions  cause  kinks,  distortion,  displacement,  or  immobility 
of  parts  of  the  colon,  they  are  often  demonstrable.  In  a  few  cases 
it  is  possible  to  make  an  early  positive  diagnosis  of  carcinoma;  in 
other  cases  the  suspected  stenosis  or  tumor  can  be  positively  located; 
10 


146  ROENTGEN-RAY  EXAMINATION 

in  others  again  the  cause  of  chronic  constipation  is  revealed.  (Plate 
XX,  Fig.  1.) 

Deviation— The  greatest  variety  of  deviations  from  the  normal 
location  of  the  colon  may  be  observed,  though  it  may  not  be  possible 
in  every  instance  to  deduce  a  pathologic  state  from  such  deviations. 

The  most  frequent  deviation  of  the  transverse  colon  is  downward 
(Plate  XVIII,  Fig.  1).  Very  marked  ptosis  (coloptosis)  is  occasion- 
ally found  in  persons  with  normal  intestinal  function.  Marked 
ptosis  of  the  transverse  colon  is  apt  to  bend  the  splenic  flexure  at  an 
angle  which  appears  in  the  roentgenogram  to  be  acute.  (Plate 
XVIII,  Fig.  2.)  These  cases  should  be  studied  laterally  or  stere- 
optically. 

Chronic  constipation  and  ptosis  of  the  transverse  colon  are  fre- 
quently associated,  but  the  causal  connection,  if  any,  between  these 
two  conditions  has  not  yet  been  made  clear.  On  the  one  hand,  it  is 
quite  conceivable  that  the  transverse  colon  in  constipated  persons 
is  dragged  down  by  the  stagnating  contents  of  the  intestine;  on  the 
other  hand,  however,  it  may  well  be  imagined  that  a  greatly 
depressed  transverse  colon  may  lead  to  constipation,  especially  if 
the  splenic  flexure  is  acutely  bent.  (Plate  XVIII,  Figs.  1,  2,  and  3.) 
In  the  ascending-colon  type  of  constipation  the  entrance  of  the 
bismuth  mass  into  the  cecum  takes  place  within  the  normal  time  of 
three  and  one-half  to  five  hours;  but  the  mass  remains  remarkably 
long  in  the  cecum  and  in  the  lower  portion  of  the  ascending  colon,  so 
that  sometimes  after  twenty-four  hours,  or  even  longer,  little  or 
none  of  the  bismuth  has  reached  the  transverse  colon.  The  bulk  of 
the  mass  may  be  gradually  moved  along,  large  remnants  remaining 
in  the  cecum  for  a  considerable  length  of  time. 

In  a  second  group  of  cases  characterized  by  ptosis  and  marked 
loop  formation  of  the  transverse  colon,  the  passage  of  the  bismuth 
mass  through  the  entire  colon  is  uniformly  retarded.  In  these 
cases  the  colon  in  its  entire  length  "seems  to  be  able  to  cast  a 
shadow  for  a  long  time  (up  to  forty  hours).     (Plate  XIX,  Fig.  1.) 

A  third  group  includes  cases  of  spastic  constipation  with  hyper- 
tonicity  of  the  lower  portion  of  the  colon  and  normal  or  decreased 
tonicity  of  the  upper  portions.  (Plate  XX,  Fig.  2.)  The  lower 
portions  appear  narrower  than  the  upper. 

A  fourth  group  is  composed  of  so-called  dyschezia  (Plate  XX, 
Fig.  4),  or  rectal  constipation  (Hertz).  In  these  cases  the  bismuth 
is  retained  for  days  in  the  sigmoid  flexure  and  in  the  rectum,  while 
the  upper  portions  of  the  colon  are  emptied  in  the  proper  time. 
Much  information  may  be  gained  by  roentgenography  in  regard  to 
the  size  and  action  of  the  rectal  valves.     (Plate  XX,  Fig.  3.) 

Cecum  Mobile. — The  pathologic  changes  of  position  of  the  colon 
include  also  the  mobile  cecum  described  by  Wilms,  which  is  readily 
diagnosed  by  means  of  the  Roentgen  ray  in  the  alternating  dorsal 
and  lateral  positions  (see  page  770). 


EXAMINATION  OF  THE  INTESTINE  147 

Volvulus  of  the  cecum  has  also  been  successfully  diagnosed  with 
tile  aid  of  the  Roentgen  ray,  the  intestine  being  filled  with  bismuth. 
It  has  been  found  that  in  infiltrating,  indurating  and  ulcerating 
processes  in  the  cecum  and  in  the  ascending  colon  the  contents  of  the 
intestine  pass  the  affected  portions  so  quickly  that  the  bismuth 
casts  no  shadow  between  the  lower  ileum  and  the  transverse  colon. 

Appendix. — As  already  stated,  the  vermiform  appendix  can  be 
visualized  in  about  50  per  cent,  of  cases.  A  diagnosis  of  chronic 
appendicitis  may  be  made  when,  first,  the  appendix  is  visualized 
and  the  pain  point  is  seen  directly  over  the  shadow  of  the  bismuth- 
filled  appendix;  second,  when  the  cecum  is  not  easily  movable  by 
external  manipulation;  and  third,  when  the  appendix  and  lower 
portion  of  the  cecum  do  not  empty  at  the  same  rate  as  the  rest  of 
the  ascending  colon. 

The  importance  of  the  appendix  in  gastro-intestinal  disease 
cannot  be  overstated.  The  Roentgen  evidences  of  appendiceal 
disease  are,  for  the  most  part,  direct.  The  most  common  are 
(a)  retention — the  degree  of  retention  usually  determining  the 
importance  of  the  appendix  as  a  factor  in  the  gastro-intestinal 
symptoms;  (6)  tenderness  localized  to  the  appendix;  (c)  kinking  or 
angulation  of  the  appendix,  indicating  that  appendiceal  drainage 
would  be  imperfect;  .(d)  irregular  filling,  suggesting  either  con- 
cretions or  constrictions;  (e)  adhesions;  (/)  position;  (g)  incompetence 
of  the  ileocecal  valve.     (Plate  XIX,  Fig.  3.) 

The  most  frequent  indirect  sign  of  appendicitis,  or  even  pathology 
in  the  right  lower  quadrant,  is  the  so-called  right-sided  position  of 
the  stomach.  We  are  often  able  to  suggest  on  the  first  gastric  study 
that  the  condition  is  one  of  right  lower  quadrant,  pathology  from 
the  fact  that  the  stomach  is  drawn  downward  and  far  to  the  right. 

In  cases  where  the  appendix  cannot  be  seen,  one  is  justified  in 
suggesting  a  diagnosis  of  appendicitis  if  there  is  tenderness  of  the 
cecum  on  deep  pressure,  and  if  there  is  cecal  fixation  and  retention, 
or  cecal  spasm.  When  manipulation  of  the  cecum  or  pressure  over 
the  appendiceal  region  produces  pain  in  the  epigastrium  in  the 
absence  of  other  disturbances,  appendicitis  is  probably  present  (see 
Aarons  sign,  page  773). 

Colonic  Stasis. — In  connection  with  the  colon,  the  most  important 
condition  for  the  internist  to  consider  is  colonic  stasis.  The  most 
common  cause  of  constipation,  as  shown  by  the  Roentgen  examina- 
tion, is  involvement  of  the  pelvic  colon  in  adhesions.  Aside  from 
the  fixation  of  the  bowel  and  tenderness  associated  with  manipula- 
tion of  the  part,  spasticity  of  the  pelvic  colon  is  always  suggestive 
of  adhesions.  The  various  deformities  of  the  cecum,  cecal  fixation, 
and  sharp  angulations  at  the  flexures  are  also  associated  with  dis- 
turbed colonic  motility.  The  diagnosis  of  carcinoma  or  other  new 
growths  involving  the  colon  is  facilitated  by  the  demonstration  of  a 
definite  defect  in  bowel  outline  or  by  an  obstruction  produced  by  the 
involvement  of  the  lumen  with  the  tumor. 


148  ROENTGEN-RAY  EXAMINATION 

Sigmoid  Flexure. — Aside  from  the  transverse  colon,  the  most 
pronounced  deviations  occur  in  the  course  and  in  the  position  of  the 
sigmoid  flexure.    (Plate  XIX,  Fig.  4.) 

Roentgen-ray  examination  may  be  of  value  in  these  cases  in 
determining  or  excluding  adhesions.  Especially  suitable  for  this 
purpose  is  the  Roentgen  fluoroscope;  during  examination  the  posi- 
tions of  the  different  loops  as  compared  with  one  another  and  their 
motility  toward  each  other  may  be  rendered  clear  by  pushing  them 
apart  with  either  the  protected  or  the  gloved  hands  or  Holzknecht's 
"detector." 

Diverticulitis. — Hernial  protrusions  develop  at  the  mesenteric 
attachment  between  the  layers  of  the  mesentery.  (See  pages  785, 
786  and  787.)  When  these  protrusions  become  inflamed  we  have 
diverticulitis.  Their  most  common  location  is  at  the  sigmoid 
flexure.  By  means  of  the  Roentgen  ray  they  can  now  be  easily 
demonstrated.     (See  Plate  XXII,  Fig.  1.) 

Hirschsprung's  Disease.— This  congenital  dilatation  of  the  lowest 
portions  of  the  colon  and  rectum  can  be  easily  recognized  by  means 
of  the  Roentgen  ray.     (Plate  XXI,  Fig.  1.) 

Stenosis. — An  enema  is  most  suitable  for  Roentgen-ray  examina- 
tion for  stenoses.  The  patient  should  assume  the  dorsal  position 
on  the  examination  table.  The  short  intestinal  tube  connected  with 
the  irrigator  is  introduced  into  the  rectum,  the  bismuth  clysma  is 
slowly  injected,  and  the  entrance  and  advance  of  the  fluid  are 
observed  on  the  screen  from  the  first  moment  until  it  reaches  the 
cecum.  At  the  same  time  the  abdomen  may  be  palpated  and 
massaged  with  the  hand,  and  the  intestinal  loops  pushed  apart  in 
order  to  obtain  greater  clearness.  The  haustral  segmentation  may 
be  absent  when  the  enema  is  given.  Under  normal  conditions  the 
entire  colon  is  filled,  up  to  the  cecum,  in  a  few  minutes,  and  for  this 
purpose  one  liter  of  fluid  is  usually  sufficient.  Insufficiency  of  the 
ileocecal  valve  may  occasionally  be  determined  by  entrance  of  the 
bismuth  into  the  lowest  portion  of  the  ileum.     (Plate  XIX,  Fig.  2.) 

In  cases  of  intestinal  stenosis  the  advance  of  the  bismuth  column 
is  halted,  according  to  the  degree  of  the  stenosis,  for  a  longer  or 
shorter  period.  If  the  stenosis  is  complete  the  shadow  ends  funnel- 
shaped  or  broadly,  and  the  filling  of  the  upper  portions  of  the  intes- 
tine is  impossible;  or  if  not  quite  complete,  the  pointed  or  broad 
ending  of  the  bismuth  sends  toward  the  upper  parts  a  narrower, 
often  irregularly  defined,  split-up  shadow.  It  is  true  that  in  stenoses 
which  are  not  very  marked  and  which  clinically  do  not  as  yet  mani- 
fest any  distinct  symptoms,  the  bismuth  column  is  also  retarded 
for  a  little  while,  but  then  the  upper  portions  of  the  colon  are 
gradually  filled  in  a  normal  maimer,  so  that  between  the  normally 
filled  intestinal  parts  which  are  situated  above  and  those  situated 
below  the  stenosis  a  distinct  absence  of  the  shadow  is  visible,  corre- 
sponding to  the  stenosed  part.     It  is  often  necessary,  for  an  exact 


EXAMINATION  OF  THE  INTESTINE  149 

diagnosis,  to  inula'  the  roentgenographic  examinations  at  different 

times,  especially  when  there  is  a  question  of  excluding  spastic 
stenoses.  A  stenosis  may  also  be  visible  on  the  Roentgen  fluoroscope 
when  the  bismuth  enema  is  allowed  to  run  out  through  the  rectal 
tube,  the  space  below  the  stenosis  being  emptied  quickly,  whereas 
the  portion  above  remains  filled  with  bismuth  and  is  emptied  only 
very  slowly.  This  method  of  examination  is  to  be  applied  also  in 
cases  of  stenosis  due  to  adhesions  and  flexures  of  the  intestine..  To 
localize  and  determine  the  degree  of  a  stenosis,  various  authors 
recommend  the  use  of  hardened  gelatin  or  glutoid  capsules  of 
different  sizes  filled  with  bismuth,  some  of  which  remain  lodged  at 
the  stenosis;  but  this  method  has  not  found  general  acceptance. 
(Plate  XXII,  Fig.  3.) 

The  diagnostic  importance  of  the  shadows  cast  by  regions  con- 
taining air  or  wrater  cannot  be  overestimated.  Some  authors  regard 
these  shadows  as  pathognomonic  of  stenosis. 

Diagnosis  of  Postoperative  Obstructions.- — A  Roentgen-ray  examina- 
tion in  postoperative  obstruction  of  the  bowTel  is  necessary  in  every 
case  before  further  operative  measures  are  employed.  By  this 
procedure  an  acute  dilatation  of  the  stomach  is  immediately 
recognized.  The  roentgenograms  reveal  gas  distention  in  the  small 
or  large  intestine,  which  may  be  easily  distinguished  by  the  charac- 
teristic outlines  of  the  gas  areas. 

Pancreas. — The  study  of  the  pancreas  is  rendered  difficult  both 
by  its  structure  and  by  its  relations.  Well  developed  cysts  of  the 
head  of  the  pancreas  have  been  recognized  during  a  Roentgen  exami- 
nation, by  the  displacement  and  change  in  the  relations  of  the  pylorus 
and  duodenum.  Carcinoma  of  the  pancreas  has  also  been  diagnosed 
by  the  disturbance  in  outline  and  relations  of  the  duodenum  produced 
by  its  presence. 

Liver.- — The  indications  for  roentgenologic  study  of  the  liver  are 
limited.  An  enlargement  of  the  liver  is  showm  sometimes  from 
distortion  of  the  diaphragm  line  or  displacement  of  the  abdominal 
contents. 

Gall  Bladder. — For  several  years  the  study  of  the  gall  bladder 
by  Roentgen  examination  was  confined  to  the  demonstration  of 
calculi  and  adhesions.  Until  recently  no  routine  examination  of  the 
gall-bladder  region  was  made,  the  question  of  adhesions  being 
determined  during  the  study  of  the  duodenum.  It  has  been 
customary  to  describe  the  so-called  gall-bladder  position  of  the 
duodenum  in  its  relation  to  the  pylorus,  and  also  to  explain  certain 
deformities  of  the  duodenum  by  assuming  periduodenal  adhesions 
complicating  a  cholecystitis.  ^Yhen  the  duodenum  was  shown 
towrard  the  median  line  and  somewhat  upward,  when  the  pylorus 
extended  a  little  too  far  to  the  right,  when  the  mobility  of  the 
duodenum  was  reduced,  and  when  tenderness  accompanied  manipu- 
lation of  the  duodenum,  we  have  assumed  the  existence  of  gall- 


150  ROENTGEN-RAY  EXAMINATION 

bladder  disease.  The  pathologic  conditions  demonstrated  have 
included  hydrops  of  the  gall  bladder,  empyema  of  the  gall  bladder, 
and  chronic  thickening  of  the  gall-bladder  wall.  Inasmuch  as  the 
normal  gall  bladder  is  rarely  demonstrated,  we  can  safely  assume 
that  a  shadow  of  this  organ  definitely  indicates  pathology. 

Gallstones. — Roentgenograph ically  about  50  per  cent,  of  gall- 
stones can  be  diagnosed.  Pure  cholesterol  stones  absorb  the  ray 
to  a  slight  extent  and  are  therefore  rarely  detected  on  the  plate. 
When  there  is  a  deposit  of  1\  per  cent,  or  more  of  calcium  the 
shadows  of  the  gallstones  are  readily  seen.  (Plate  XXI,  Figs.  3  and 
4.)  The  smaller  the  quantity  of  bile  in  the  gall  bladder,  the  more 
easily  can  gallstones  be  demonstrated.  When  there  are  periduodenal 
or  perigastric  adhesions  due  to  cholecystitis  the  stomach  and  duo- 
denal cap  assume  a  characteristic  position  (Plate  XXI,  Fig.  3) .  The 
presence  of  gall-bladder  disease  can  often  be  surmised  from  the  ap- 
pearance of  the  bismuth-filled  stomach.  If  adhesions  are  present,  due 
to  chronic  inflammation  of  the  gall  bladder,  the  pyloric  portion  of  the 
stomach  is  usually  pulled  well  over  to  the  right,  extending  often- 
times two  or  three  inches  beyond  the  median  line.  The  appearance 
of  the  duodenal  cap  in  these  cases  is  also  characteristic.  If  the 
adhesions  do  not  involve  the  duodenal  cap  sufficiently  to  distort  it, 
we  will  find  that  the  cap  makes  an  acute  angle  with  the  stomach  so 
that  the  peak  of  the  cap  is  drawn  upward  and  to  the  left.  This 
abnormal  position  of  the  stomach  to  the  right  of  the  median  line, 
and  the  angulation  of  the  cap,  constitute  the  so-called  gall-bladder 
position  of  the  stomach,  and  may  indicate  a  pathologic  condition 
of  the  biliary  ducts  or  gall  bladder.  In  plates  of  the  gall-bladder 
region,  a  much  thickened  gall  bladder  will  often  show  a  distinct 
outline,  due  to  the  fact  that  the  infiltrated  mucosa  casts  a  differ- 
entiating shadow. 

Spleen. — The  differential  diagnosis  of  tumors  in  the  upper  left 
quadrant  can  be  aided  by  the  demonstration  of  the  splenic  outline. 
In  order  to  show  this  organ,  it  is  necessary  to  distend  the  stomach 
with  gas,  and  also  to  have  considerable  liquid  in  the  stomach. 
With  the  patient  on  the  right  side,  with  the  above  conditions 
complied  with,  the  splenic  outline  is  frequently  very  well  shown. 

Peritoneal  Inflation.- — The  injection  of  oxygen  into  the  peritoneal 
cavity  is  one  of  the  newer  procedures  which  bids  fair  to  make  pos- 
sible many  diagnoses  now  considered  difficult.  Enough  oxygen  is 
injected  into  the  free  peritoneal  cavity  to  form  a  background  of 
lessened  density  against  which  the  visceral  organs  are  graphically 
displayed.  In  this  way  the  outline  of  the  liver,  the  size,  shape  and 
position  of  the  spleen,  the  presence  or  absence  of  adhesions,  and  the 
easier  demonstration  of  gallstones,  with  visualization  of  the  outline 
of  the  gall  bladder,  will  be  realized. 


CHAPTER  VI. 
DIET  IN  GASTRIC  DISEASES. 

For  practical  purposes  food  may  be  defined  as  any  substance 
which,  when  taken  into  the  body,  assists  in  its  nutrition  and  main- 
tenance, or  replaces  its  waste  and  losses.  Food  has  two  main  func- 
tions^— namely,  the  provision  for  growth  and  repair  of  the  animal 
body,  and  as  a  source  of  potential  energy  to  be  converted  into 
heat  and  work.  Substances  which  may  not  serve  either  of  these 
functions  may  yet  fulfil  a  useful  place  in  a  dietary.  Such  articles 
as  tea,  coffee,  and  meat  extractives,  while  they  cannot  be  properly 
classed  as  foods,  are  important,  nevertheless,  in  the  consideration 
of  dietetics. 

Food  as  it  is  ingested  differs  widely  in  its  composition  from  the 
nutrient  material  ultimately  required  for  the  repair  of  waste  and 
the  sustenance  of  the  body.  Before  it  can  be  utilized  in  the  animal 
economy  it  must  undergo  a  more  or  less  complex  process,  desig- 
nated "digestion,"  which  means  alteration  in  the  alimentary  tract 
by  certain  unorganized  ferments  (enzymes). 

Diet  plays  the  most  important  part  in  the  treatment  of  diseases 
of  the  stomach.  In  prescribing  diet  for  patients  with  gastric  dis- 
ease of  any  kind,  great  care  should  be  exercised  to  avoid  that 
which  will  tend  to  irritate  the  affected  stomach.  A  properly  selected 
diet  usually  fulfils  a  number  of  indications,  such  as  diminution  of 
the  production  of  mucus,  or  increased  or  decreased  secretion  of 
acid;  it  will  obviate  the  danger  of  overburdening  the  muscular 
coats,  and  in  this  way  fortify  the  tone  of  the  stomach.  Reduction 
of  abnormal  fermentative  processes  may  be  accomplished  by  a 
properly  selected  diet. 

The  progress  made  in  the  treatment  of  diseases  of  the  stomach 
and  intestine  has  been  due  mainly  to  more  accurate  knowledge 
of  the  chemical  composition  of  food  and  of  the  changes  that  take 
place  within  the  human  organism.  Simple  methods  of  examining 
the  stomach  contents  have  inclined  physicians  to  make  greater  use 
of  the  stomach  tube  to  ascertain  qualitative  and  quantitative  devi- 
ations from  the  normal  in  gastric  digestion.  The  results  obtained 
by  accurate  analysis  render  the  prescribing  of  proper  diet  a  com- 
paratively easy  matter.  Since  we  are  able  to  remove  and  examine 
the  stomach  contents  at  will,  we  can  adapt  the  treatment  to  the 
disease  much  better  than  would  be  possible  if  dietetic  directions 
had  to  be  given  without  the  laboratory  aids. 

Heat  Value  of  Foods. — The  heat  values  of  the  various  foodstuffs 
have  been  determined  by  experiment,  and  the  result  is  expressed 
in  calories.    A  calorie  is  the  amount  of  heat  required  to  raise  the 


152  DIET  IN  GASTRIC  DISEASES 

temperature  of  one  kilogram  of  water  1°  C,  or  approximately 
the  amount  required  to  raise  the  temperature  of  one  pound  of 
water  4°  F.  According  to  Atwater,  1  gram  of  protein  furnishes 
4  calories,  1  pound  1820;  1  gram  of  fat  furnishes  9  calories,  and 
1  pound  4004;  1  gram  of  carbohydrate  furnishes  4  calories,  and 
1  pound  1820.  The  caloric  value  of  foods  must  be  borne  in  mind. 
Patients  suffering  from  gastric  disease  are  usually  placed  on  a  too 
restricted  diet;  the  number  of  caloric  units  is  too  small,  and  as  a 
consequence  the  patients  rapidly  lose  flesh.  It  is  absolutely  neces- 
sary in  all  cases  of  chronic  disease  of  the  stomach  to  see  that  the 
patient  obtains  the  required  number  of  calories  every  twenty-four 
hours. 

Fat  in  the  form  of  butter  is  one  of  the  best  foods  for  developing 
heat  without  injuring  the  stomach.  In  all  chronic  diseases  of  the 
stomach,  fat  agrees  well.  In  many  diseases  of  the  digestive  organs 
the  most  satisfactory  progress  has  been  made  by  adding  great 
quantities  of  fat  to  the  dietary.  Investigations  in  metabolism  have 
verified  this  conclusion. 

Dietary  Regulations  and  Lists.— The  experience  which  the  patient 
has  gained  in  reference  to  his  own  diet  should  be  taken  into  con- 
sideration when  prescribing  a  diet  for  him.  The  postulate  of  Boas, 
"  throw  away  the  printed  dietary  lists,"  is  based  upon  the  desire 
to  escape  from  monotonous  routine  in  the  treatment  of  patients 
suffering  from  gastric  disorders,  inasmuch  as  it  is  not  possible  to 
satisfy  the  subjective  sensations  of  the  patients  by  means  of  fixed 
rules.  Patients  frequently  maintain  that  they  are  unable  to  digest 
certain  articles  of  food.  Such  assertions  vary,  but  they  cor- 
respond to  the  peculiar  nature  of  gastric  digestion,  inasmuch  as 
the  assimilability  of  certain  articles  of  food  differs  markedly  in 
different  patients.  The  habits  of  the  patient  are  likewise  to  be 
taken  into  consideration.  The  preference  for  or  objection  to  cer- 
tain foods,  the  desire  for  change  or  for  certain  modes  of  prepara- 
tion, the  behavior  of  the  patient  as  to  appetite  and  the  sensation 
of  hunger,  are  all  of  great  importance  when  considering  the  selec- 
tion of  a  menu.  Appetite  and  hunger  are  trustworthy  guides  to 
the  healthy  man  for  the  food  requirements  of  the  body.  In  health, 
as  much  food  as  the  normal  appetite  calls  for  is  generally  eaten; 
this  corresponds,  as  a  rule,  to  the  quantity  which  can  be  assimilated 
and  by  which  the  body  weight  is  kept  fairly  constant  for  a  con- 
siderable space  of  time.  In  patients  with  disease  of  the  stomach 
the  appetite  and  the  sensation  of  hunger  are,  as  a  rule,  not  a  trust- 
worthy guide  for  the  quantity  of  food  required;  in  most  cases  both 
are  below  normal. 

When  this  is  the  case,  the  diet  must  be  regulated  in  such  a  manner 
that  nutrition  does  not  suffer  on  account  of  the  deficient  appetite. 
To  diet  does  not  mean  to  starve.  It  is  also  of  great  importance 
to  search  for  the  causes  of  the  anorexia.  These  may  consist  of 
organic  disease  of  the  stomach,  or  they  may  be  of  a  purely  nervous 


COMPOSITION  OF  COMMON  AMERICAN  FOOD  PRODUCTS     153 

Average  Composition  of  Common  American  Food  Products 
(Atwater). 


Food  materials  (as  purchased). 

Refuse. 

Water. 

Pro- 
tein. 

(  ";trbr>- 
l':it           hy- 
drates. 

Ash. 

Fuel 

value 

per 

pound. 

Animal  Food. 

Per 

Per        Per 

Per 

Per 

Per 

Calo- 

Beef, fresh: 

cent. 

cent.     cent. 

cent. 

cent. 

cent. 

ries. 

16.3 

52.6      15.5 

15.0      

0.8 

910 

Flank 

10.2 

54.0      17.0 

19.0 

.7 

1105 

13.3 

52.5      16.1 

17.5 

.9 

1025 

12.7 

52.4      19.1 

17.9 

.8 

1100 

12.8 

54.0      16.5 

16.1 

.9 

975 

27.6 

45.9      14.5 

11.9 

.7 

1165 

Ribs 

20.8 

43.8      13.9 

21.2 

.7 

1135 

Rib  rolls 

63.9      19.3 

16.7 

.9 

1055 

7.2 

60.7      19.0 

12.8 

1.0 

890 

20.7 

45.0      13.8 

20.2 

.7 

1090 

36.9 

42.9      12.8 

7.3 

.6 

545 

16.4 

56.8 

16.4 

9.8 

.9 

715 

18.7 

49.1 

14.5 

17.5 

.7 

905 

15.7 

50.4 

15.4 

18.3 

.7 

1045 

Beef,  corned,  canned,  pickled,  and  dried: 

8.4 

49.2 

14.3 

23.8 

4.6 

1245 

6.0 

58.9 

11.9 

19.2 

4.3 

1010 

Dried,  salted,  and  smoked      .... 

4.7 

53.7 

26.4 

6.9 

8.9 

790 

Canned  boiled  beef 

51.8 

25.5 

22.5 

1.3 

1410 

Canned  corned  beef 

51.8 

26.3 

18.7 

4.0 

1270 

Veal: 

21.3 

52.0  :  15.4 

11.0 

.8 

745 

14.2 

60.1      15.5 

7.9 

.9 

625 

3.4 

68 . 3     20 . 1 

7.5 

1.0 

695 

24.5 

54.2      15.1 

6.0 

.7 

535 

20.7 

56.2  ,  16.2 

6.6 

.8 

580 

Mutton: 

Flank 

9.9 
18.4 

39.0  !   13.8 
51.2      15.1 

36.9 

.6 
.8 

1770 

14.7      

890 

Loin  chops 

16.0 

42.0      13.5 

28.3 

.7 

1415 

21.2 

41.6      12.3 

24.5 

.7 

1235 

Hind  quarter,  without  tallow 
Lamb: 

17.2 

45.4 

13.8 

23.2 

.7 

1210 

19.1 

17.4 

45.5 
52.9 

15.4 
15.9 

19.1 
13.6 

.8 
.9 

1075 

860 

Pork,  fresh: 

10.7 

48.0 

13.5 

25.9 

.8 

1320 

19.7 

41.8 

13.4 

24.2 

.8 

1245 

12.4 

44.9 

12.0 

29.8 

.7 

1450 

Tenderloin 

66.5 

18.9 

13.0 

1.0 

895 

Pork,  salted,  cured,  and  pickled: 

13.6 

34.8 

14.2 

33.4 

4.2 

1635 

18.2 

36.8 

13.0 

26.6 

5.5 

1335 

Salt  pork 

7.9        1.9 

86.2 

3.9 

3555 

7.7 

17.4       9.1 

62.2 

4.1 

2715 

Sausage: 

3.3 

55  2      18  2 

19.7 

3.8 

1155 

Pork 

39.8 

13.0 

44.2 

1.1 

2.2 

2075 

Frankfort 

57.2 

19.6 

18.6 

1.1 

3.4 

1155 

Soups: 

Celery,  cream  of 

88.6       2.1 

2.8 

5.0 

1.5 

235 

Beef 

92.9        4.4 

.4 

1.1 

1.2 

120 

Meat  stew 

84  5       4  6 

4.3 

5.5 

1.1 

365 

Tomato 

90.0        1.8 

1.1 

5.6 

1.5 

185 

Poultry: 

41.6 

43.7     12.8 

1.4 

.7 

305 

25.9 

47.1      13.7 

12.3 

.7 

765 

17.6 

38.5     13.4 

29.8 

.7 

1475 

22.7 

42.4      16.1 

18.4 

.8 

1060 

29.9 

58.5     11.1 

.2 

.8 

220 

Halibut,  steaks  or  sections      .... 

17.7 

61.9      15.3 

4.4 

.9 

475 

44.7 

40.4      10.2 

4.2 

.7 

370 

Perch,  yellow,  dressed        .            ... 

35.1 

50.7      12.8 

.7      

.9 

275 

50.1 

35.2        9.4 

4.8  ;  

.7 

380 

Shad  roe v  . 

71.2      20.9 

3.8 

2.6 

1.5 

600 

Fish,  preserved: 

Cod,  salt 

24.9 

40.2      16.0 

.4 

18.5 

325 

44.4 

19  2      20  5 

8.8 

7.4 

755 

1  Refuse,  oil. 


154 


DIET  IN  GASTRIC  DISEASES 


Average  Composition  of  Common  American  Food  Products 
(  Atw  ate  r)  — continued . 


Food  materials  (as  purchased).             j  Refuse. 

Water. 

Pro- 
tein. 

Fat. 

Carbo- 
hy- 
drates. 

Ash. 

Fuel 

value 

per 

pound. 

Animal  Food — continued. 

Per 

Per 

Per 

Per 

Per 

Per 

Calo- 

Fish, canned: 

cent. 

cent. 

cent. 

cent. 

cent. 

cent. 

ries. 

Salmon 

63.5 

21.8 

12.1 

2.6 

915 

Sardines        

"  5 .Oil 

53.6 

23.7 

12.1 

5.3 

950 

Shellfish: 

Oysters,  "solids" 

88.3 

6  0 

1.3 

3.3 

1.1 

225 

Clams 

80.8 

10.6 

1.1 

5.2 

2.3 

340 

Crabs      

52.4 

36.7 

7.9 

.9 

.6 

1.5 

200 

Lobsters 

61.7 

30.7 

5.9 

.7 

.2 

.8 

145 

Eggs:   Hens'  eggs 

11. 21 

65.5 

13.1 

9.3 

.9 

635 

Dairy  products,  etc. : 

Butter 

11.0 

1.0 

85.0 

3.0 

3410 

Whole  milk 

87.0 

3.3 

4.0 

5.0 

.7 

310 

Skim  milk 

90.5 

3.4 

.3 

5.1 

.7 

165 

Buttermilk 

91.0 

3.0 

.5 

4.8 

.7 

160 

Condensed  milk 

26.9 

8.8 

8.3 

54.1 

1.9 

1430 

Cream     .      . " 

74.0 

2.5 

18.5 

4.5 

.5 

865 

Cheese,  Cheddar 

27.4 

27.7 

36.8 

4.1 

4.0 

2075 

Cheese,  full  cream        .... 

34.2 

25.9 

33.7 

2.4 

3.8 

1885 

Vegetable  Food. 

Flour,  meal,  etc.: 

Entire-wheat  flour 

11.4 

13.8 

1.9 

71.9 

1.0 

1650 

Graham  flour 

11.3 

13.3 

2.2 

71.4 

1.8 

1645 

Wheat  flour,  patent  roller  process: 

High-grade  and  medium 

12.0 

11.4 

1.0 

75.1 

.5 

1635 

Low  grade      

12.0 

14.0 

1.9 

71.2 

.9 

1640 

Macaroni,  vermicelli,  etc. 

10.3 

13.4 

.9 

74.1 

1.3 

1645 

Wheat  breakfast  food        .... 

9.6 

12.1 

1.8 

75.2 

1.3 

1680 

Buckwheat  flour 

13.6 

6.4 

1.2 

77.9 

.9 

1605 

Rye  flour 

12.9 

6.8 

.9 

78.7 

.7      1620 

Corn  meal 

12.5 

9.2 

1.9 

75.4 

1.0      1635 

Oat  breakfast  food 

7.7 

16.7 

7.3 

66.2 

2.1      1800 

Rice 

12.3 

8.0 

.3 

79.0 

.4 

1620 

Tapioca 

11.4 

.4 

.1 

88  0 

.1 

1650 

Starch     

90  0 

1675 

Bread,  pastry,  etc.: 

White  bread 

35.3 

9.2 

1.3 

53.1 

1.1 

1200 

Brown  bread 

43.6 

5.4 

1.8 

47.1 

2.1 

1040 

Graham  bread 

35.7 

8.9 

1.8 

52.1 

1.5 

1195 

Whole-wheat  bread      .... 

38.4 

9.7 

.9 

49.7 

1.3 

1130 

Rye  bread 

35.7 

9  0 

.6 

53.2 

1.5 

1170 

Cake 

19.9 

6.3 

9.0 

63.3 

1.5 

1630 

Cream  crackers 

6.8 

9.7 

12.1 

69.7 

1.7 

1925 

Oyster  crackers       .      . 

4.8 

11.3 

10.5 

70.5 

2.9 

1910 

Soda  crackers 

5.9 

9.8 

9.1 

73.1 

2.1 

1875 

Sugars,  etc.: 

Molasses 

70.0 

1225 

Candy2 

96.0 

1680 

Honey 

81.0 

1420 

Sugar,  granulated 

100.0 

1750 

Maple  syrup 

71.4 

1250 

Vegetables:3 

Beans,  dried 

12.6 

22.5 

1.8 

59.6 

3.5 

1520 

Beans,  Lima,  shelled    .... 

68.5 

7.1 

.7 

22.0 

1.7 

540 

Beans,  string 

'  7.0 

83.0 

2.1 

.3 

6.9 

.7 

170 

Beets 

20.0 

70.0 

1.3 

.1 

7.7 

.9 

160 

Cabbage       

15.0 

77.7 

1.4 

.2 

4.8 

.9 

115 

Celery 

20.0 

75.6 

.9 

.1 

2.6 

.8 

65 

Corn,  green  (sweet) ,  edible  portion 

75.4 

3.1 

1.1 

19.7 

.7 

440 

Cucumbers  ...:... 

15.0 

81.1 

.-7 

.2 

2.6 

.4 

65 

Lettuce 

15.0 

80.5 

1.0 

.2 

2.5 

.8 

65 

Mushrooms 

88.1 

3.5 

.4 

6.8 

1.2 

185 

Onions 

10.0 

78.9 

1.4 

.3 

8.9 

.5 

190 

Parsnips 

20.0 

66.4 

1.3 

.4 

10.8 

1.1 

230 

1  Refuse,  shell. 

-  Plain  confectionery  not  containing  nuts,  fruit,  or  chocolate. 

3  Such  vegetables  as  potatoes,  squash,  beets,  etc.,  have  a  certain  amount  of  inedible  material, 
skin,  seeds,  etc.  The  amount  varies  with  the  method  of  preparing  the  vegetables,  and  cannot  be 
accurately  estimated.  The  figures  given  for  refuse  of  vegetables,  fruits,  etc.,  are  assumed  to 
represent  approximately  the  amount  in  these  foods  as  ordinarily  prepared. 


COMPOSITION  OF  COMMON  AMERICAN  FOOD  PRODUCTS     155 


Average  Composition  of  Common  American  Food  Products 
(Atwater) — continued. 


Food  materials  (as  purchased). 

Refuse. 

Water. 

Pro- 
tein. 

Fat. 

(_':trliu- 

hy- 
drates. 

Ash. 

Fuel 

value 

per 

pound. 

Vegetable  Food — continued. 

Per 

Per 

Per 

Per 

Per 

Per 

Calo- 

Vegetables— continued : 

cent. 

cent. 

cent. 

cent. 

cent. 

cent. 

ries. 

Peas  (Pisum  sativum),  dried 

9.5 

24.6 

1.0 

62.0 

2.9 

1505 

Peas  (Pisum  sativum),  shelled 

74.6 

7.0 

.5 

16.9 

1.0 

440 

Cowpeas,  dried        .... 

13.0 

21.4 

1.4 

60.8 

3.4 

1505 

Potatoes 

'20.0 

62.6 

1.8 

.1 

14.7 

.8 

295 

Rhubarb 

40.0 

56.6 

.4 

.4 

2.2 

.4 

60 

Sweet  potatoes        .... 
Spinach 

20.0 

55.2 

1.4 

.6 

21.9 

.9 

440 

92.3 

2.1 

.3 

3.2 

2.1 

95 

Squash 

50.0 

44.2 

.7 

.2 

4.5 

.4 

100 

Tomatoes 

94.3 

.9 

.4 

3.9 

.5 

100 

Turnips 

Vegetables,  canned: 

30.0 

62.7 

.9 

.1 

5.7 

.6 

120 

Baked  beans 

68.9 

6.9 

2.5 

19.6 

2.1 

555 

Peas  (Pisum  sativum),  green 

85.3 

3.6 

.2 

9.8 

1.1 

235 

Corn,  green 

76.1 

2.8 

1.2 

19.0 

.9 

430 

Succotash 

75.9 

3.6 

1.0 

18.6 

.9 

425 

Tomatoes 

94.0 

1.2 

.2 

4.0 

.6 

95 

Fruits,  berries,  etc.,  fresh: 

Apples 

25. 0l 

63.3 

.3 

.3 

10.8 

.3 

190 

Bananas       

35.0 

48.9 

.8 

.4 

14.3 

.6 

260 

Grapes 

25.0 

58.0 

1.0 

1.2 

14.4 

.4 

295 

Lemons 

30.0 

62.5 

.7 

.5 

5.9 

.4 

125 

Muskmelons 

50.0 

44.8 

.3 

4.6 

.3 

80 

Oranges 

27.0 

63.4 

.6 

"!i 

8.5 

.4 

150 

Pears 

10.0 

76.0 

.5 

.4 

12.7 

.4 

230 

Persimmons,  edible  portion    . 

66.1 

.8 

.7 

31.5 

.9 

550 

Raspberries 

85.8 

1.0 

12.6 

.6 

220 

Strawberries 

"  5.0 

85.9 

.9 

".6 

7.0 

.6 

150 

Watermelons     .    '. 

59.4 

37.5 

.2 

.1 

2.7 

.1 

50 

Fruits,  dried: 

Apples 

28.1 

1.6 

2.2 

66.1 

2.0 

1185 

Apricots 

29.4 

4.7 

1.0 

62.5 

2.4 

1125 

Dates 

10.0 

13.8 

1.9 

2.5 

70.6 

1.2 

1275 

Figs 

18.8 

4.3 

.3 

74.2 

2.4 

1280 

Raisins 

10.0 

13.1 

2.3 

3.0 

68.5 

3.1 

1265 

Nuts: 

Almonds       

45.0 

2.7 

11.5 

30.2 

9.5 

1.1 

1515 

Brazil  nuts 

49.6 

2.6 

8.6 

33.7 

3.5 

2.0 

1485 

Butternuts 

86.4 

.6 

3.8 

8.3 

.5 

.4 

385 

Chestnuts,  fresh      .... 

16.0 

37.8 

5.2 

4.5 

35.4 

1.1 

915 

Chestnuts,  dried     .      .      .      . 

24.0 

4.5 

8.1 

5.3 

56.4 

1.7 

1385 

Cocoanuts 

48. 82 

7.2 

2.9 

25.9 

14.3 

.9 

1295 

Cocoanuts,  prepared    . 

3.5 

6.3 

57.4 

31.5 

1.3 

2865 

Filberts 

52.1 

1.8 

7.5 

31.3 

6.2 

1.1 

1430 

Hickory  nuts 

62.2 

1.4 

5.8 

25.5 

4.3 

.8 

1145 

Pecans,  polished     .... 

53.2 

1.4 

5.2 

33.3 

6.2 

.7 

1465 

Peanuts        .      .      . 

24.5 

6.9 

19.5 

29.1 

18.5 

1.5 

1775 

Pifion  (Pinus  edulis)     . 

40.6 

2.0 

8.7 

36.8 

10.2 

1.7 

1730 

Walnuts,  black        .... 

74.1 

.6 

7.2 

14.6 

3.0 

.5 

730 

Walnuts,  English    .... 

58.1 

1.0 

6.9 

26.6 

6.8 

.6 

1250 

Miscellaneous: 

Chocolate 

5.9 

12.9 

48.7 

30.3 

2.2 

2625 

Cocoa,  powdered     .... 

4.6 

21.6 

28.9 

37.7 

7.2 

2160 

Cereal  coffee,  infusion  (1  part  boiled  in 

20  parts  water)3 

98.2 

.2 

1.4 

.2 

30 

1  Fruits  contain  a  certain  proportion  of  inedible  materials,  as  skin,  seeds,  etc.,  which  are  properly 
classed  as  refuse.  In  some  fruits,  as  oranges  and  prunes,  the  amount  rejected  in  eating  is  practi- 
cally the  same  as  refuse.  In  others,  as  apples  and  pears,  more  or  less  of  the  edible  material  is 
ordinarily  rejected  with  the  skin  and  seeds  and  other  inedible  portions.  The  edible  material 
which  is  thus  thrown  away,  and  should  properly  be  classed  with  the  waste,  is  here  classed  with  the 
refuse.  The  figures  for  refuse  here  given  represent,  as  nearly  as  can  be  ascertained,  the  quantities 
ordinarily  rejected. 

2  Milk  and  shell. 

3  The  average  of  five  analyses  of  cereal  coffee  grain  is:  Water,  6.2;  protein,  13.3;  fat,  3.4; 
carbohydrates,  72.6;  and  ash,  4.5  per  cent.  Only  a  portion  of  the  nutrients,  however,  enters  into 
the  infusion.  The  average  in  the  table  represents  the  available  nutrients  in  the  beverage.  Infu- 
sions of  genuine  coffee  and  of  tea  like  the  above  contain  practically  no  nutrients. 


156  DIET  IN  GASTRIC  DISEASES 

nature.  The  diminished  appetite  may  have  been  induced  artifi- 
cially by  a  dietary  plan  which  the  patient  himself  had  determined 
upon  before  seeking  medical  advice.  The  statements  of  patients 
regarding  the  digestibility  and  general  effects  of  certain  articles  of 
food  must  not  be  accepted  unreservedly  as  a  guide  to  treatment. 

Average  Composition  of  Common  American  Food  Products  (Atwater). 
—The  table  on  pages  153,  154  and  155,  compiled  by  Atwater,  taken 
from  Bulletin  No.  142  of  the  United  States  Department  of  Agri- 
culture, gives  the  average  composition  of  ordinary  American  food 
materials,  with  the  percentage  of  refuse. 

Digestibility  is  a  term  which  is  frequently  misunderstood  and 
misapplied.  Digestibility  does  not  involve  the  question  of  distress, 
nor  the  question  of  the  food  containing  sufficient  calories;  for  not 
every  food  which  is  well  digested  is  well  borne,  and  not  every 
food  which  is  well  borne  is  digested  well  and  assimilated  properly. 
The  amount  of  digestive  effort  required  varies  with  different 
articles  of  diet.  A  person  whose  gastro-intestinal  tract  is  normal 
can  digest  and  assimilate  without  discomfort  any  kind  of  reasonable 
food  which  he  can  eat. 

The  term  "digestible"  signifies,  however,  something  quite 
different  in  gastric  disease.  Riegel  defines  a  diet  as  easily  diges- 
tible which  does  not  make  great  demand  on  the  secretory  and  motor 
functions  of  the  stomach,  and  which  is  easily  absorbed  without 
producing  subjective  discomforts.  This  definition  also  includes 
assimilability,  or  good  effect  after  absorption.  Wegele  claims  that 
a  food  is  easily  digestible  when  it  fulfils  the  following  conditions: 
(1)  It  must  offer  but  little  resistance  to  the  digestive  juices;  that 
is,  it  must  be  easily  soluble.  (2)  It  must  not  impede  the  peristaltic 
movements,  nor,  on  the  other  hand,  should  it  accelerate  the  move- 
ments of  the  stomach  too  much.  (3)  It  must  not  seriously  irritate 
the  digestive  organs  chemically  or  mechanically.  (4)  It  must  be 
easy  of  absorption,  either  from  the  stomach  or  from  the  intestine. 

Experience  teaches  that  emaciation  and  loss  of  strength  must 
be  referred,  in  the  majority  of  cases  of  gastric  disease,  to  insuffi- 
cient nutrition.  It  is  therefore  important  to  know  the  quantity 
of  food  absolutely  needed  by  the  body.  In  health  the  require- 
ments for  the  average  adult  are  100  grams  of  protein,  50  grams  of 
fat,  and  450  grams  of  carbohydrate,  daily.  Expressed  in  calories, 
the  number  is  2720.  Individual  articles  of  diet  may  be  substituted 
one  for  another  in  proportion  to  their  heat  values.  Obviously  the 
constitution  and  the  appetite  of  the  patient  offer  certain  limits 
which  must  be  respected.  If  one  or  more  ordinarily  desirable 
articles  of  diet  are  not  acceptable  to  the  patient,  we  may  substitute 
others,  so  long  as  we  supply  the  required  number  of  heat  units. 
When  considering  this  question,  it  is  important  to  remember  that 
a  person  at  rest  requires  fewer  calories  than  one  at  work.  In  health 
the  requirements  per  kilo  of  body  weight  per  day,  at  rest,  are  30  to 


VITAMIN  157 

35  calories;  at  light  labor,  35  to  40  calories;  and  at  average  labor, 
40  to  45  calories.  In  the  treatment  of  severe  chronic  gastric  dis- 
ease the  patients  should  be  confined  to  bed  in  order  to  economize 
the  heat  units  contained  in  the  comparatively  small  amount  of 
food  they  are  able  to  take. 

Vitamin. — It  has  been  proved  that,  besides  protein,  carbohydrates, 
fat,  mineral  salts,  and  water,  another  substance  is  essential  to  the 
maintenance  of  orderly  metabolism  and  the  proper  nutrition  of  the 
body.  This  substance  is  called  "vitamin."  When  vitamin  is  lacking, 
nutritional  "deficiency"  or  "avitamin"  diseases  develop,  extreme 
examples  of  which  are  beriberi,  scurvy,  and  rickets. 

As  long  ago  as  1897  the  disastrous  effects  of  an  exclusive  diet 
of  polished  rice  on  the  nutrition  of  fowls  was  discovered  (Eyckman) ; 
and  at  the  same  time  it  was  shown  that  fowls  suffering  from  poly- 
neuritis as  a  result  of  the  feeding  with  polished  rice  recovered 
promptly  under  a  diet  of  undecorticated  rice.  (It  cannot  be  said 
even  now  that  the  birds  deprived  of  the  antineuritic  vitamin  to  the 
point  of  prostration  from  polyneuritis  are  not  permanently  injured, 
but  the}''  respond  rapidly  in  general  condition  to  feeding  with  the 
rice  polishings  or  an  extract  made  from  them,  or  to  a  diet  of  yeast 
extract.)  Not  only  rice,  but  bread  and  milk,  supplied  the  material 
for  the  early  investigation  of  the  presence  of  a  previously  unsuspected 
vital  principle.  By  extracting  a  mixture  of  milk  and  bread  with 
ether  and  alcohol,  it  was  found  that,  while  the  residue  contained  the 
well  known  protein  and  other  chemical  ingredients  of  these  articles, 
something  was  missing,  and  that  mice,  which  can  flourish  on  a  diet  of 
unmodified  bread  and  milk,  would  perish  if  given  no  other  food  than 
the  modified  mixture  (Stepp).  The  extract  contained  a  principle 
analogous  to  that  contained  in  the  polishings  of  rice;  for  when  it  was 
fed  to  the  starving  mice  they  recovered  their  wonted  health.  In 
1911  this  vital  principle  was  named  "vitamin"  by  Casimir  Funk. 
Other  names  have  been  suggested  since,  but  all  workers  in  the  science 
of  nutritional  deficiency  now  employ  the  term  "vitamin." 

The  presence  of  vitamin  in  milk  was  demonstrated  by  Osborne  and 
Mendel  and  by  Hopkins  about  1910,  by  feeding  small  quantities  of 
the  milk,  in  its  natural  condition  or  protein-free,  to  animals  reduced 
in  vitality  by  living  on  "purified"  proteins  and  other  foods.  The 
stimulating  effect  of  the  milk  on  such  animals  was  out  of  all  propor- 
tion to  the  known  nutritive  principles  contained  in  this  fluid,  even 
in  its  natural,  protein-bearing  state.  Then  McCollum  and  Davis 
discovered  the  fact  that  butter  and  the  yolk  of  eggs  contained  an 
ingredient  that  could  not  be  classified  simply  as  fat  or  oil,  for  it 
had  a  peculiar  stimulating  effect  on  growth,  differentiating  it  clearly 
from  lard  and  olive  oil. 

Meanwhile  the  preparation  of  extracts  of  rice  polishings  and  other 
vitamin-containing  substances  proceeded.  An  efficient  alcoholic 
extract  of  rich  polishings  was  made  by  Fraser  and  Stanton  in  1907; 


158  DIET  IN  GASTRIC  DISEASES 

and  in  1911  Funk  showed  that  pressed  yeast  hydrolized  with  sulphuric 
acid  had  the  same  effect  as  rice  polishings  in  curing  polyneuritis  in 
birds.  Thus  one  by  one  were  the  sources  of  vitamin  being  dis- 
covered, and  methods  of  extraction  devised.  But  it  soon  became 
evident  that  there  was  more  than  one  vitamin — that  the  occult 
substances  extracted  from  grains,  egg  yolk,  etc.,  were  classifiable 
according  to  their  physiologic  effects;  that  polyneuritis  in  birds  and 
beriberi  in  man  were  not  the  only  results  of  vitamin-deficiency  in  the 
food;  and  that  the  remedy  in  each  instance  must  be  related  to  the 
cause. 

Among  other  effects  of  vitamin-deficiency  the  following  have 
been  clearly  established:  xerophthalmia,  an  edematous  affection  of 
the  eyes,  not  curable  by  medicinal  means  or  local  applications,  and 
leading  ultimately  to  total  blindness;  rachitis;  and  scurvy. 

The  vitamins,  not  being  chemically  identifiable,  have  been 
grouped  in  two  classes  according  to  their  solubility,  as  "fat-soluble" 
(soluble  in  fat-solvents)  and  "water-soluble."  And  it  has  now  be- 
come necessary  to  subdivide  the  latter  into  two  classes,  called 
respectively  "B"  and  "C,"  the  fat-soluble  vitamin  being  known  as 
"A." 

Although  vitamins  are  present  in  a  great  variety  of  food  sub- 
stances, if  the  food  is  to  be  selected  for  vitamin  purposes  it  is  well 
to  make  the  selection  from  among  those  which  contain  an  abundance 
of  the  particular  vitamin  desired.  The  fat-soluble  "A"  vitamin 
(indicated  in  xerophthalmia,  rickets,  dental  caries,  and  impaired 
bodily  growth)  is  abundant  in  butter,  eggs,  and  cod-liver  oil,  and 
fairly  plentiful  in  cabbage,  carrots,  cream,  milk,  sweet  potatoes, 
spinach,  and  whole  wheat  flour.  Water-soluble  "B"  vitamin  (indi- 
cated in  beriberi,  impaired  growth,  and  a  general  condition  of 
malnutrition)  is  abundant  in  navy  beans,  soy  beans,  sweetbread 
(pancreas),  yeast,  and  whole  wheat  flour,  and  fairly  plentiful  in 
bananas,  carrots,  cauliflower,  celery,  Indian  corn  or  whole  corn  meal, 
milk,  oats,  onions,  parsnips,  peanuts,  potatoes,  rutabaga,  spinach, 
and  whey.  Water-soluble  "C"  vitamin  (indicated  in  scurvy, 
actual  or  threatened)  is  abundant  in  apples,  fresh  cabbage,  lettuce, 
onions,  oranges,  fresh  peas,  and  spinach,  and  fairly  plentiful  in 
potatoes  and  tomatoes. 

This  list  is  not  complete;  but  more  important  than  a  more  extended 
list,  perhaps,  is  the  consideration  that,  though  present  in  certain 
vegetables  in  the  natural  state,  vitamins  are  influenced  in  varying 
degrees  by  heat  and  by  acids  and  alkalis.  The  different  classes 
of  vitamins  thus  far  discovered  (there  may  be  others  awaiting  dis- 
covery, or  what  are  now  classed  under  one  head  may  be  found  to 
belong  under  two  or  more)  have  been  grouped  according  to  their 
stability  with  reference  to  temperature,  acids  and  alkalis  as  follows 
(Drummond):  "A,"  stable  at  100°  C,  probably  at  140°  C;  "B," 
comparatively  stable  at  100°  C,  slowly  destroyed  at  120°  C.  and 


MEAT  159 

above;  "(',"  gradually  destroyed  above  50°  ('.,  rapidly  destroyed 
above  80°  C.  "A,"  stable  in  cold  alkali,  probably  stable  in  acids; 
"  15,"  slowly  destroyed  in  cold  alkali,  rapidly  in  hot,  comparatively 
stable  in  acids;  "C,"  rapidly  destroyed  even  in  cold  alkali,  compara- 
tively stable  in  acids  below  50°  C.  These  calculations  are  not  in- 
tended to  be  taken  as  anything  but  approximations.  The  "B" 
vitamins  appear  to  be  uninjured  by  long  boiling  with  acids,  and  it  has 
been  claimed  that  the  "A"  type  as  found  in  butter  will  withstand 
the  effect  of  live  steam.  The  "C"  vitamin  is  least  resistant  to 
extraneous  influences;  but,  on  the  other  hand,  it  is  not  necessarily 
subject  to  such  influences  when  appropriated  in  the  form  of  fruits 
— apples,  oranges,  and  lemons.  The  antiscorbutic  vitamin  in  milk 
is  probably  injured  or  destroyed  by  pasteurization;  hence  the 
desirability  of  giving  bottle-fed  babies  a  little  orange  juice,  since 
their  diet  consists  entirely  of  milk.  The  boiling  process  may  injure 
or  extract  the  "  B"  or  "  C"  vitamins  in  potatoes  and  other  vegetables, 
but  in  baking  the  intense  heat  of  the  oven  does  not  penetrate  to  the 
interior.  In  eggs,  which  contain  "A"  vitamin  mostly,  the  vitamin 
is  retained  despite  boiling  or  poaching.  The  "C"  vitamin  in 
cabbage  cannot  survive  boiling;  to  obtain  it  in  this  food,  the  latter 
must  be  served  cold — as  "slaw." 

It  has  been  shown  experimentally  that  both  the  fat-soluble  "A" 
and  the  water-soluble  "B"  vitamins  are  essential  to  normal  growth — 
of  rats,  fowl,  swine,  etc.,  and  inferentially  of  man.  The  water- 
soluble  "C"  vitamin  is  absolutely  essential  to  health,  as  are  the  other 
two,  but  its  absence  is  not  manifested  otherwise,  so  far  as  known, 
than  by  the  development  of  scurvy. 

The  vitamins  are  not  nutrients  in  any  sense  of  the  word.  So 
far  are  they  from  taking  the  place  of  any  of  the  well  known  con- 
stituents of  a  normal  diet  that  their  administration  will  often  stimu- 
late the  appetite;  in  indicated  cases  more  food  than  before  is  made 
physiologically  available,  and  hence  more  is  demanded,  though  the 
equivalent  of  the  former  ration  is  more  completely  utilized  than  it 
would  be  without  the  necessary  vitamins. 

The  three  vitamins  in  extract  form  are  now  obtainable  for  medicinal 
use,  being  marketed  under  the  name  metagen.  Metagen  is  sup- 
plied in  capsules  of  0.3  Gm.  (5  grains)  each — one  ordinary  dose. 

Meat. — Much  discussion  has  taken  place  regarding  the  respec- 
tive merits  of  light  and  dark  meat.  The  significance  of  the  dis- 
tinction has  frequently  been  exaggerated,  but  certain  differences 
should  not  be  disregarded.  White  meat  (veal,  fowl)  possesses  a 
shorter,  softer,  and  more  tender  fiber,  and  differs  from  dark  meat, 
such  as  beef  and  mutton,  by  its  smaller  proportion  of  extractives; 
this  difference  is  considerable.  The  fat  of  dark  meat  is  with  diffi- 
culty dissolved,  and  therefore  offers  resistance  to  penetration  by 
the  digestive  juices.  Meat  may  be  defined  as  the  muscle  of  an 
animal  together  with  the  conjoined   connective-tissue   substances, 


160  DIET  IN  GASTRIC  DISEASES 

such  as  tendons,  ligaments,  bones,  and  cartilage.  The  internal 
organs  of  the  animal,  so  far  as  they  are  edible,  namely,  kidneys, 
spleen,  liver,  sweetbread,  brain,  and  intestine,  as  well  as  sea-foods, 
such  as  fish,  lobster,  and  clam,  are  also  included  under  the  term 
"meat."  The  average  composition  of  meat  is:  protein,  20  to  25 
per  cent.;  fat,  gelatinous  substances,  glycogen,  and  extractives 
(kreatin,  xanthin) .  The  meat  of  animals  recently  killed  should  be 
permitted  to  hang  for  some  time  before  it  is  eaten.  While  meat 
is  hanging,  lactic  acid  is  produced  which  loosens  the  connective 
tissue  between  the  muscle  fibers,  thereby  softening  it  and  render- 
ing it  more  easily  digestible.  Game  should  hang  for  a  time  to 
permit  of  this  softening  process,  especially  for  patients  with  gastric ' 
troubles;  but  it  should  not  be  allowed  to  decompose  so  far  as  to 
become  "gamey,"  for  then  it  is  likely  to  arouse  the  aversion  of 
the  patient  or,  if  eaten,  to  increase  the  digestive  disturbances  by 
introducing  into  the  system  the  products  of  decomposition.  Old 
animals  naturally  yield  tougher  meat  than  young. 

The  preparation  of  meat  is  important.  Raw  meat  ought  to  be 
avoided  by  patients  with  gastric  disease,  though  it  is  more  easily 
digested  in  health  than  is  cooked  meat.  The  digestion  of  raw 
meat  takes  place  both  in  the  stomach  and  in  the  small  intestine; 
the  coarse  connective  tissue  is  digested  by  the  stomach,  the  muscle 
fiber  by  the  small  intestine.  The  stomach  cannot,  however,  digest 
raw  meat  when  the  secretion  of  hydrochloric  acid  is  defective;  on 
the  other  hand,  when  there  is  too  much  hydrochloric  acid,  still 
more  of  it  is  produced  under  the  stimulus  of  raw  meat  in  the  stom- 
ach. The  dictum  of  Schmidt  to  strike  out  raw,  rare,  and  smoked 
meat  from  the  diet  of  gastric  patients  is  therefore  a  reasonable  one. 
Smoked  and  canned  meats  behave  similarly  toward  hydrochloric 
acid.  Salted  or  canned  meats,  such  as  ham,  ox  tongue,  smoked 
or  corned  beef,  have  not  the  same  nutritive  value  as  raw  meat  or 
meat  prepared  in  any  other  way;  during  the  pickling  process, 
extractive  materials  and  phosphates  are  lost.  In  partaking  of 
uncooked  meats  there  is  always  a  possibility  of  infection  by  animal 
parasites.  The  custom  among  the  German  people  of  eating  raw 
pork  is  well  known.  Thousands  of  microscopists  are  employed  in 
Germany  to  prevent  trichinosis.  Stiles  found  that  of  274  cases  of 
trichinosis  in  America  208  were  Germans.  The  simplest  and  most 
effective  method  of  preventing  the  disease  is  ignored.  The  cooking 
of  the  meat  is  all  that  is  necessary. 

The  majority  of  people  eat  more  meat  than  they  require.  Meat 
once  a  day  is  sufficient  for  a  person  not  engaged  in  manual  labor, 
or  for  one  who  does  not  take  much  vigorous  outdoor  exercise.  A 
high  blood-pressure  may  be  more  or  less  lowered  by  excluding  meat 
from  the  diet,  Acute  rheumatic  patients  are  better  off  without 
meat.  Many  gastric  troubles  owe  their  origin  to  the  consumption 
of  food  which  causes  a  greater  drain  on  the  gastric  juices  than  the 


GELATIN— BEEF  TEA—EQGS  101 

system  is  able  to  stand.  Of  the  various  meats,  young  lean  beef 
is,  as  a  rule,  the  most  easily  digested.  The  white  meat  of  a  fowl 
enjoys  a  special  reputation,  to  which  most  clinicians  agree;  yet  no 
chemical  differences  between  the  white  meat  and  dark  meat  have 
yet  been  shown. 

The  digestibility  of  roasted,  boiled,  and  stewed  meats  is  in  the 
order  named.  It  may  be  increased  by  preliminary  processes  such 
as  beating,  grinding,  mincing,  and  scraping.  Meats  poor  in  fat 
are  generally  easily  digestible,  owing  to  the  ready  accessibility  of  the 
connective  tissue  to  the  gastric  juice.  The  following  varieties  are 
permissible  for  gastric  patients:  Beef,  veal,  lamb,  lean  pork,  hare, 
deer,  fowl,  squab,  partridge,  pheasant,  and  all  kinds  of  lean  fish, 
such  as  trout,  pike,  codfish,  and  shad.  Because  of  their  high  per- 
centage of  fat,  goose,  herring  and  salmon  should  be  avoided.  Caviar, 
though  rather  salty,  may  be  allowed,  as  may  also  oysters  and 
lobsters.  The  meat  of  the  lobster  is  not  so  tough  and  difficult 
to  digest  as  is  popularly  believed.  Sausage  should  be  avoided 
because  it  contains  about  40  per  cent,  of  fat  and  a  great  deal  of 
condiment. 

Gelatin. — Foods  containing  gelatin  belong  to  the  group  of  meat 
nutrients.  They  are  of  great  importance  in  dietetics,  serving  as 
protein  and  fat  sparers.  Gelatin  is  almost  entirely  digested,  leaving 
little  or  no  residue.  Tendons,  cartilage,  ligaments,  connective  tissue, 
and  bones  belong  to  this  class.  Gelatin  is  present  in  larger  amount 
in  the  broth  of  veal  than  in  beef  broth.  Calf's  head  and  calf's  feet 
are  rich  in  gelatin.  Meat  jelly  is  a  popular  gelatinous  food  for 
patients  with  stomach  disease.  Meat  broth  is  not  considered  a 
food,  since  it  contains  only  small  quantities  of  protein,  fat,  and 
gelatin.  It  is,  however,  rich  in  extractives  which  stimulate  the 
secretion  of  hydrochloric  acid.  The  indications  for  its  use  are 
therefore  plain.  Bouillon  soups  containing  eggs  or  flour  may  be 
substituted  for  pure  meat  broths. 

Beef  Tea. — Pure  beef  tea  has  much  the  same  value  as  meat  broth. 
It  contains  rather  more  protein  and  gelatinous  substances  than  broth, 
and  has  a  marked  effect  in  stimulating  the  appetite,  favoring  the 
secretion  of  gastric  juice  in  cases  of  acute  and  chronic  affections 
of  the  stomach.  Beef  tea  is  prepared  by  taking  fresh  meat  free 
from  fat  and  cutting  it  into  small  pieces,  placing  it  in  a  bottle 
without  water,  and  slowly  heating  it  on  the  water -bath;  after 
steaming  for  twenty  minutes  the  meat  juice  collects  as  a  turbid, 
yellowish  fluid.     (See  page  177.) 

Eggs. — Eggs  are  to  be  taken,  as  such,  only  when  soft  boiled, 
the  white  coagulated.  In  the  form  of  very  light  egg  dishes,  or 
stirred  up  in  soups,  they  make  a  very  acceptable  addition  to  the 
diet.  Hard-boiled  or  fried  eggs  cannot  readily  be  reached  by 
the  gastric  juice,  and  are  apt  to  irritate  a  diseased  gastric  mucous 
membrane,  unless  the  hard  protein  is  first  very  finely  triturated. 
11 


162  DIET  IN  GASTRIC  DISEASES 

They  are  valuable,  however,  in  cases  of  hyperchlorhydria.  Eggs  are  a 
concentrated  food  containing  13  per  cent,  of  protein  and  9  per  cent, 
of  fat.  A  diet  consisting  solely  or  chiefly  of  eggs  should  not  be  pre- 
scribed for  patients  with  gastric  trouble,  since  even  in  health  it  is  not 
advisable  to  ingest  large  quantities  of  protein  in  so  concentrated  a 
form.  If  the  functional  derangement  of  the  stomach  is  marked  by 
subacidity,  the  peptonizing  power  is  of  course  deficient;  and  if  by 
hyperacidity,  the  secretion  of  acid  will  be  still  further  augmented 
by  the  ingestion  of  protein.  Raw  eggs  are  not  assimilated  as  well  as 
boiled  eggs.  They  frequently  cause  diarrhea  and  vomiting.  It  is 
estimated  that  only  50  per  cent,  of  the  whites  of  raw  eggs  is  utilized 
in  the  human  digestive  tract.  This  assertion  may  be  somewhat 
startling,  but  the  recent  work  of  Mendel,  Lewis,  Ely,  and  Bateman 
proves  it  to  be  true.  Raw  egg-white  contains  something,  in  small 
amount,  which  has  a  powerful  retarding  or  inhibiting  action  on  the 
digestive  enzymes.  This  is  destroyed  by  heat.  The  egg  should  be 
coagulated  by  heat  to  favor  its  digestion  and  assimilation. 

Fat. — A  diet  rich  in  fat  was  at  one  time  considered  deleterious 
to  patients  with  gastric  disease.  At  present,  however,  the  view 
predominates  that  fat  is  a  food  which  is  very  well  adapted  to  this 
class  of  patients,  inasmuch  as  it  has  a  high  caloric  value  in  propor- 
tion to  its  volume.  We  know,  moreover,  that  fat  hinders  the  secre- 
tion of  gastric  juice,  while  it  does  not  interfere  with  the  motility 
of  the  stomach.  Good  results  have  been  reported  after  the  admin- 
istration of  fat  in  cases  of  disturbed  motor  activity  of  this  organ. 
The  fat  best  adapted  to  patients  with  gastric  disease,  as  has  been 
said,  is  butter.  There  are  but  few  trustworthy  substitutes  for  good 
butter.  Of  other  fats  suitable  for  patients  with  stomach  diseases, 
we  have  cream,  olive  oil,  oil  of  sesame,  sweet  oil  of  almond,  and 
cod-liver  oil.  Because  of  its  disagreeable  taste  cod-liver  oil  proves 
repulsive  to  most  patients;  the  taste  may  be  disguised  by  admin- 
istering the  oil  in  capsules. 

Milk.- — Since  milk  contains  large  proportions  of  protein,  fat,  carbo- 
hydrate, and  vitamin,  it  is  an  excellent  article  of  diet.  When  a  liquid 
diet  alone  is  indicated,  milk  holds  first  place.  It  must,  however, 
be  borne  in  mind  that  milk  alone  is  unable  to  supply  the  required 
number  of  calories,  for  three  liters  of  milk  contain  only  1800  calories. 
Should  milk  prove  repulsive  to  a  patient,  the  taste  may  be  dis- 
guised by  combining  it  with  other  articles  of  diet.  Milk  ought  to 
be  given  freshly  boiled,  as  it  is  then  more  easily  digested,  and  the 
germs  contained  in  it  are  destroyed  by  the  boiling  process.  Milk 
is  poorly  borne  by  many  patients,  and  for  various  reasons.  Some- 
times the  reason  is  purely  subjective,  a  sort  of  "  phobia"  that 
has  to  be  overcome  by  psychic  influence.  Then,  again,  with  a 
pure  milk  diet  a  large  quantity  is  necessary  in  order  to  provide 
the  required  number  of  calories,  and  this  large  volume  interferes 
with  the  digestion  of  the  milk.    The  volume  may  be  diminished 


MILK  163 

I>y  the  use  of  condensed  milk.    The  stomach  contents  are  apt  to 

become  excessively  acid  when  great  quantities  of  milk  are  taken, 
the  acid -secreting  glands  being  stimulated  by  the  presence  of  the 
milk.  When  it  is  considered  advisable  to  prescribe  milk  in  large 
amounts,  the  hyperacidity  may  be  corrected  by  the  use  of  alkaline 
mineral  waters  in  small  amounts,  beginning  during  the  second 
hour  of  gastric  digestion.  The  addition  of  lime-water  to  milk  will 
often  aid  in  its  digestion  in  cases  in  which  the  milk  would  not 
otherwise  be  easily  borne.  Milk  is  nearly  always  well  borne  if 
it  does  not  remain  too  long  in  the  stomach.  The  more  finely  the 
casein  floccules  are  precipitated  the  less  discomfort  is  the  patient 
likely  to  experience  from  a  milk  diet.  The  drinking  or  sipping  of 
milk  in  very  small  quantities  will  cause  a  fine  precipitation  of 
casein  in  the  stomach.  Part  of  the  pronounced  value  of  koumiss 
and  kefir  is  due  to  the  precipitation  of  casein  in  a  finely  subdivided 
condition.  Pegnin,  a  sterile  milk-sugar  rennet  ferment,  has  a 
similar  action  in  producing  a  finely  floccular  coagulation.  It  is 
found  that  milk  causes  much  discomfort  in  cases  of  stenosis  of  the 
pylorus. 

Karell  Cure.— For  certain  disorders,  such  as  dropsical  conditions 
of  all  kinds,  whether  due  to  the  heart,  the  kidneys  or  the  liver;  for 
asthma  resulting  from  emphysema  and  pulmonary  catarrh;  obstinate 
neuralgia;  hypertrophy  and  fatty  degeneration  of  the  liver,  and  all 
obscure  conditions  of  the  gastro-intestinal  tract  and  the  nervous 
system,  a  type  of  milk  diet  advocated  by  the  Russian  physician, 
Karell,  has  proved  useful.    The  patient  is  kept  on  this  diet  until  all 
the  acute  symptoms  have  subsided  and  then  gradually  placed  on  one 
more    nutritious.     This,  the  so-called  "Karell  cure,"  consists  in 
limiting  all  foods  taken  by  the  patient  to  skimmed  milk  in  amounts 
of  two  to  six  ounces  (60  to  200  Cc.)  at  exact  intervals,  four  times  a 
day.    It  can  be  taken  at  any  temperature  preferred  by  the  patient's 
taste,  and  should  be  sipped  or  "chewed"  so  that  it  will  be  intimately 
mixed  with  the  saliva.    If  it  is  well  digested,  as  proved  by  solid 
stools,  the  amount  is  gradually  increased  until  at  the  end  of  two 
weeks  one  quart  (1000  Cc.)  is  allowed.     Karell  insists  upon  the 
observance  of  regular  intervals  between  the  milk  meals — 8  o'clock, 
12,  4  and  8.    During  the  first  week  some  difficulty  is  encountered, 
and  each  feeding  seems  a  very  tiny  dose,  yet  if  the  patients  follow 
the  rule  they  complain  of  neither  hunger  nor  thirst.    Constipation 
is  relieved  by  simple  enemata.    If  thirst  is  distressing,  a  little  plain 
water  or  seltzer  is  allowed.    If  the  desire  for  solid  food  in  the  second 
or  third  week  is  overpowering,  an  allowance  of  food  from  the  purin- 
free  list  is  gradually  added  to  the  diet.    Absolute  rest  in  bed  is  essen- 
tial.   The  "  cure"  is  indicated  in  cases  of  high  blood-pressure;  decom- 
pensated acute  and  chronic  heart  disease  associated  with  cyanosis, 
dyspnea,   edema,   and   ascites;   arteriosclerosis,    kidney  and  liver 
diseases,  gout,  and  rheumatic  arthritis.     In  many  cases  a  prompt 


164  DIET  IN  GASTRIC  DISEASES 

and  efficient  diuresis  results  in  loss  of  weight  and  disappearance  of 
all  edema.  The  improvement  in  the  subjective  symptoms  is  often 
marvellous. 

Should  milk  as  such  not  be  permissible,  advantage  may  be  taken 
of  one  or  more  of  the  numerous  milk  preparations  available. 

Buttermilk  contains  less  fat  and  sugar  than  fresh  milk,  but  the 
small  percentage  of  lactic  acid  it  contains  gives  it  an  agreeable 
and  refreshing  taste;  it  is  well  borne  in  gastric  disease  and  is 
particularly  useful  in  febrile  affections  of  the  stomach. 

Whey,  the  fluid  remaining  after  the  precipitation  of  casein,  con- 
tains protein,  milk-sugar,  peptone,  and  common  salt;  its  nutritive 
value  is  small,  and  it  is  used  to  a  very  limited  extent  (see  page  690). 

Koumiss  and  Kefir. — Koumiss  and  kefir,  on  the  other  hand, 
are  most  excellent  milk  preparations.  Koumiss  is  prepared  from 
the  milk  of  either  mares  or  cows  by  lactic  acid  and  alcoholic  fer- 
mentation. It  contains  lactic  acid,  carbon  dioxid,  and  alcohol, 
and  has  an  agreeable,  slightly  acid  taste.  Kefir  has  been  used 
much  more  extensively  than  koumiss.  It  is  prepared  by  means 
of  kefir  tablets  or  pastilles,  which  acting  upon  milk  produce  lactic 
and  alcoholic  fermentation,  the  result  of  which  is  a  thick,  cream- 
like, acidulous  beverage.  Boiled  milk,  cooled,  is  poured  over  the 
kefir  ferment  and  left  to  stand  for  twelve  hours  at  ordinary  room 
temperature.  It  is  then  stirred,  filtered,  and  placed  in  bottles, 
which  are  to  be  thoroughly  shaken  three  times  a  day  and  kept  in 
a  cool  place.  After  two  or  three  days  the  kefir  will  be  ready  for 
consumption.  The  advantage  of  kefir  is  that  it  contains  small 
quantities  of  carbon  dioxid  together  with  a  very  small  percentage 
(2  per  cent.)  of  alcohol.  When  ingested  it  hastens  the  secretion 
of  hydrochloric  acid  and,  on  account  of  the  action  of  the  carbon 
dioxid,  increases  its  power. 

Yoghurt. — This  is  a  Bulgarian  sour  milk,  of  recent  introduction 
in  America,  but  long  used  in  the  East.  It  has  a  high  nutritive 
value,  employed  in  the  same  way  as  kefir  (see  page  691). 

The  value  of  yoghurt  (pronounced  yogoort)  for  gastric  patients 
was  first  appreciated  by  the  Bulgarian  physician  Grigoroff,  and 
later  by  the  French  school.  It  is  similar  in  many  ways  to  kefir 
and  koumiss.  The  acidulation  is  generated  by  a  ferment  con- 
taining three  kinds  of  bacteria,  the  most  important  of  which  is  the 
Bacillus  bulgaricus,  a  long  bacillus  which  appears  both  singly  and 
in  chains,  and  which  can  be  stained  by  Gram's  method.  This 
bacillus  is  able  to  induce  fermentation  of  dextrose,  sugar  of  milk, 
and  saccharose,  and  causes  the  coagulation  of  sterile  milk  within 
twelve  hours  by  the  formation  of  lactic  acid.  A  temperature  of 
60°  to  70°  C.  destroys  the  vitality  of  the  germ  in  thirty  minutes. 
The  composition  of  yoghurt  and  its  relation  to  ordinary  sour 
milk  (which  becomes  acid  by  mere  exposure  to  air),  to  kefir,  and 
to  koumiss,  may  be  seen  from  the  following  table: 


Common 

Koumiss. 

sour  milk. 

Yoghurt . 

0.80  1 

\  2.70 
0.98 

o.:;n 

3.55 

1.04  J 

'3.75 

1.12 

3.70 

7.20 

0.39 

4.50 

9.40 

0.96 

0.60 

0.80 

3.19 

0.20 

0.33 

0.71 

1.38 

CHEESE— BREAD  165 

Kefir, 

Lactocasein  .  .  .  .2.98 
Lacto-albumin  .  .  .  0.28 
Peptones  mid  albunioses     0.05 

Fat 3.10 

Milk-sugar  .  .  .  .  2.78 
Lactic  acid     .      .      .      .     0.81 

Alcohol 0.70 

Mineral  constituents      .     0.79 

The  advantage  of  yoghurt  consists  in  the  fact  that  its  casein 
and  albumin  are  rendered  soluble  in  the  shape  of  peptones  and 
albunioses,  and  that  the  lime  phosphates  have  gone  into  solu- 
tion up  to  G8  per  cent.  These  facts  serve  to  explain  the  ready 
digestibility  of  the  milk. 

Metchnikoft'  ascribes  a  direct  life -prolonging  effect  to  yoghurt 
milk,  and  he  bases  this  opinion  upon  the  fact  that  in  Bulgaria, 
where  yoghurt  is  a  regular  article  of  diet,  there  are  in  four  million 
inhabitants  three  thousand  six  hundred  consumers  of  yoghurt  who 
are  said  to  be  above  one  hundred  years  of  age,  while  in  Germany, 
with  a  population  of  sixty -one  million,  there  are  only  about  seventy 
centenarians.  Granted  that  the  conclusions  of  Metchnikoff  may 
be  somewhat  erroneous,  it  must  still  be  admitted  that  the  decom- 
position process  in  the  intestine  and  the  whole  tissue  metamor- 
phosis are  favorably  affected  by  the  use  of  yoghurt.  Preparations 
analogous  to  yoghurt  are  put  out  by  the  various  pharmaceutical 
houses  in  America.  Tablets  are  manufactured  from  a  pure  cul- 
ture of  Bulgarian  lactic  acid  bacilli,  which  when  added  to  sweet 
milk  induce  fermentation,  the  result  being  a  beverage  that  is 
essentially  the  same  as  yoghurt. 

Cheese. — Cheese  is  made  by  treating  raw  milk  with  rennet. 
The  resulting  coagulum  is  thoroughly  beaten  up,  and  then  left 
standing  to  mature.  The  casein  is  thereby  split  up  into  various 
decomposition  products  which  give  the  cheese  its  characteristic 
odor  and  taste.  Decomposed  cheese,  which  is  looked  upon  as  a 
delicacy  by  some  people,  should  not  be  prescribed  for  patients 
with  gastric  disease.  Almost  every  normal  stomach  rebels  against 
the  Roquefort  and  Limburger  cheeses  with  their  characteristic 
odors.  The  semiputrid  casein  cheese  should  never  be  eaten  even 
by  healthy  people,  not  to  mention  people  with  impaired  digestion. 

Bread. — Rye  bread  is  prepared  from  rye  flour  by  means  of 
yeasted  dough.  Black  bread  and  "pumpernickel"  are  made  from 
rye  flour;  Graham  bread  from  whole  wheat  meal.  All  these  varie- 
ties must  be  excluded  from  the  diet  of  gastric  patients,  inasmuch 
as  they  prove  a  source  of  irritation  to  any  but  a  normal  stomach. 
The  finer  baked  foods,  especially  those  made  of  wheat,  as  white 
bread,  zwieback,  and  cookies  or  biscuits  prepared  by  the  addition 
of  butter,  milk,  and  sugar,  are  especially  adapted  for  gastric  treat- 
ment.   Ordinary  wheat  bread  should  be  given  stale,  or  only  when 


166  DIET  IN  GASTRIC  DISEASES 

roasted — as  toast.  Fresh  and  very  soggy  wheat  bread  retards 
penetration  by  the  digestive  fluids  and  is  difficult  of  mechanical 
subdivision.  Wheat  bread  toasted,  zwieback,  and  biscuits,  like 
the  crust  of  bread,  contain  their  starch  in  the  form  of  dextrin  which 
is  easily  digested.  It  is,  however,  necessary  that  patients  with  gastric 
disease  should  carefully  masticate  and  insalivate  these  baked  foods. 
There  is  a  mistaken  idea  among  the  laity  that  the  sick  should 
be  fed  pappy,  liquid  substances  entirely  different  from  the  food 
taken  by  a  person  in  health.  If  we  except  foods  that  contain  a 
great  deal  of  irritating  waste,  there  is  no  reason  why,  in  general,  the 
diet  of  the  sick  should  differ  from  that  of  the  well.  We  must,  how- 
ever, eliminate  fried  foods  and  fermentable  vegetables.  Pure  white 
bread  is  never  contra-indicated,  and  the  addition  of  butter  gives 
it  a  high  caloric  value.  The  bread  should  be  thoroughly  toasted 
in  order  to  dextrinize  the  carbohydrates  and  render  them  easily 
digestible.    Crackers  can  frequently  be  substituted  for  bread. 

Gruels. — Grain  flours  are  used  not  only  in  the  baking  of  bread, 
but  in  the  preparation  of  soups.  The  gruel  soups  in  the  making  of 
which  the  grain  granules  are  first  boiled  and  then  pressed  through  a 
sieve  are  valuable  in  the  treatment  of  stomach  diseases.  Oat  and 
barley  gruel  are  prepared  after  this  manner.  Their  mucoid  con- 
sistency is  due  to  gluten  and  broken-up  starch  granules.  Gruel 
soups  protect  the  mucous  membrane  of  the  stomach  from  the 
irritating  effects  of  other  foods  eaten  at  the  same  time.  Sago  and 
tapioca  as  porridge  or  soup  are  very  useful  foods  for  gastric  patients. 
Noodles,  macaroni  and  spaghetti  are  useful  farinaceous  dishes. 

Potatoes. — The  cheapness  of  potatoes  and  the  large  percentage 
of  carbohydrates  they  contain  render  them  a  very  satisfactory  food 
for  all  classes  of  gastric  patients.  They  must  be  properly  pre- 
pared-— as  a  puree,  if  need  be,  with  the  addition  of  milk  and  butter. 
Other  tuberous  plants  used  as  foods  are  much  poorer  in  carbohy- 
drates than  potatoes,  and  should  be  eaten  only  when  they  can  be 
prepared  in  the  form  of  puree.  Hard  tubers,  such  as  radishes, 
beet  roots,  and  onions,  are  contra-indicated  in  cases  of  impaired 
digestion. 

Rice. — Rice  has  usually  been  considered  an  inferior  food  owing 
to  the  excess  of  starch  (in  other  words,  deficiency  of  protein)  in  its 
composition;  and  this  is  undoubtedly  true  of  rice  as  we  usually 
get  it.  This  alleged  defect  in  the  grain  is  due  to  the  removal  of 
a  nutrient  substance  in  making  it  presentable  for  the  market  by 
what  is  known  as  the  polishing  process.  Not  only  the  outer  husk, 
but  what  is  known  as  the  "rice  meal,"  which  envelops  the  inner 
kernel,  is  removed,  despite  the  fact  that  this  is  the  most  nutritious 
part  of  the  grain.  Analysis  of  "rice  meal"  shows  it  to  contain 
12.5  per  cent,  of  protein  and  4.5  per  cent,  of  phosphoric  acid. 
The  Japanese,  in  common  with  other  rice-eating  peoples,  polish 
only  the  grain  that  is  intended  for  export;  what  is  kept  for  home 


VEGETA  BLES—FR  UI T—S  UGAR— SPICES  1 67 

consumption,  being  unpolished,  possesses  a  much  larger  proportion 
of  nutriment  and  a  flavor  which  the  polished  grain  lacks.  Rice 
in  its  natural  condition  is  therefore  a  very  nutritious  article  of 
food;  it  is  easily  digested,  and  quite  suitable  for  patients  with 
impaired  digestion.  The  polished  rice  is  so  deficient  in  vitamin  that 
animals  fed  solely  upon  it  develop  polyneuritis  analogous  to  that 
which  occurs  in  beriberi.     (See  page  157.) 

Green  Vegetables. — Green  vegetables  and  the  various  kinds  of 
cabbage  contain  very  little  protein  and  only  a  small  quantity  of 
carbohydrates.  Prepared  as  purees  they  are  permissible,  however. 
The  small  percentage  of  cellulose  in  green  vegetables  is  no  contra- 
indication to  their  use.  A  patient  with  gastric  disease  should  not, 
however,  eat  vegetables  which  cannot  be  finely  divided.  Of  aspara- 
gus, the  tops  only  are  allowable.  Mushrooms  are  contra-indicated. 
Green  vegetable  leaves  are  rich  in  vitamin  (see  page  158). 

Legumes. — Peas,  beans  and  lentils  are  all  rich  in  protein,  con- 
taining about  20  or  25  per  cent.,  and  50  per  cent,  of  carbohydrates. 
They  are  consequently  very  nutritious  substances,  and,  when  well 
cooked  and  carefully  strained,  suitable  for  gastric  patients. 

Fruit. — Fruit  contains  less  protein  than'  do  vegetables,  but  a 
larger  quantity  of  carbohydrates  in  the  shape  of  dextrose  and 
levulose.  The  refreshing  taste  of  fruit  is  due  to  various  fruit  acids, 
such  as  malic  acid  in  apples,  tartaric  acid  in  grapes,  and  citric  acid 
in  lemons.  Patients  with  gastric  disease  should  take  fruit  only 
when  it  is  cooked  by  boiling. 

Sugar. — Cane-sugar,  grape-sugar,  milk-sugar,  or  fruit-sugar  may 
be  eaten  by  patients  with  gastric  disease,  within  certain  limits. 
Solutions  of  sugar  cause  in  the  stomach  a  decreased  secretion 
by  the  gastric  glands.  Since  they  inhibit  the  secretion  of  hydro- 
chloric acid,  they  are  applicable  in  conditions  of  hyperacidity. 
Morgan  carefully  experimented  with  cane-sugar  on  several  persons, 
making  repeated  gastric  analyses;  he  concluded  that  sugar  in  con- 
siderable amounts  in  the  diet  of  either  the  healthy  or  the  sick 
depresses  the  secretory  functions  of  the  stomach.  In  hyperchlor- 
hydria  a  diet  containing  large  amounts  of  sugar  diminishes  the 
secretion  of  hydrochloric  acid  in  about  the  same  proportion  as  it 
does  in  a  healthy  stomach.  Three  or  four  ounces  of  sugar  can  be 
digested  by  the  healthy  adult  without  difficulty  in  twenty-four 
hours.    Saccharin  occasionally  gives  rise  to  disturbed  digestion. 

Spices. — Small  quantities  of  common  salt  stimulate  the  secretion 
of  gastric  juice;  large  quantities  hinder  digestion.  The  ingestion  of 
salt  in  gastric  disease  has  to  be  regulated  according  to  the  findings 
on  analysis  of  the  stomach  contents.  In  cases  of  achlorhydria 
salt  is  indicated,  while  in  cases  of  hyperchlorhydria  it  is  contra- 
indicated.  In  addition  to  sodium  chlorid,  the  alkaline  phosphates 
and  earths  are  made  use  of  in  the  human  economy.  They  are, 
however,  present  in  ordinary  food  in  sufficient  quantity  for  this 


168  DIET  IN  GASTRIC  DISEASES 

purpose.  Only  very  few  spices  should  be  allowed  in  the  dietary  of 
gastric  patients.  Vanilla  and  cinnamon  are  harmless.  Practically 
all  other  spices  must  be  eliminated,  or  used  with  care  for  the  purpose 
of  stimulating  an  insufficient  secretion  of  gastric  juice. 

Water.— Artificial  waters  charged  with  carbon  dioxid  have  no  place 
in  the  dietary  of  stomach  patients.  The  natural  mineral  waters, 
however,  excite  peristaltic  action  and  have  a  slightly  anesthetic 
effect  upon  the  mucous  membrane  of  the  stomach.  Strong  natural 
waters,  like  the  artificial  substitutes,  contain  too  much  carbon 
dioxid,  and  consequently  have  a  harmful  effect  upon  the  stomach. 
Not  more  than  eight  ounces  of  water  should  be  taken  at  one  time. 
Water  is  not  absorbed  by  the  stomach.  The  drinking  of  ice-water 
is  harmful,  inasmuch  as  it  temporarily  paralyzes  the  pyloric  closure, 
so  that  the  stomach  contents  are  in  danger  of  being  emptied  at 
once  into  the  duodenum.  As  Bettmann  has  shown,  large  draughts 
of  hot  water  benefit  those  who  are  well  nourished  and  whose  diges- 
tive tract  is  well  supplied  with  muscular  tissue.  Large  draughts  of 
hot  water,  taken  on  retiring,  are  beneficial  to  corpulent  people  who 
are  subject  to  "bilious  attacks"  so  called,  or  who  are  affected  with 
gastric  catarrh.  An  aperient  pill  swallowed  at  bedtime  with  a 
large  tumblerful  of  hot  water  is  usually  all  the  medicine  that  is 
necessary  to  keep  such  patients  comfortable.  Hot  water  taken 
before  meals,  either  with  or  without  phosphate  or  sulphate  of  soda, 
is  also  beneficial.  It  acts  by  dissolving  and  washing  out  of  the 
stomach  the  accumulated  mucus.  Such  treatment,  however,  insti- 
tuted in  cases  of  motor  insufficiency  (atony,  dilatation),  almost 
invariably  does  harm.  At  first  the  patients  experience  some  relief, 
but  after  a  few  weeks  all  their  symptoms  return  in  an  aggravated 
form.  This  is  explained  by  the  fact  that  when  the  digestive  tract 
is  relaxed  and  muscularly  weak  the  stomach  is  unable  to  propel 
large  quantities  of  fluid  into  the  intestine.  In  such  cases  it  is 
always  difficult  to  get  sufficient  water  into  the  system.  The  stomach 
should  not  be  overloaded  with  water  at  any  one  time,  but  water 
should  be  taken  in  small  quantities  and  frequently. 

Recent  experiments  on  dogs  prove  that  the  ingestion  of  quanti- 
ties of  water  with  food  causes  a  marked  increase  both  in  the  quan- 
tity of  the  gastric  juice  and  in  its  hydrochloric  acid  content. 

Alcohol. — The  combustion  of  protein  and  fat  is  diminished  after 
small  quantities  of  alcohol  are  taken.  In  acting  as  a  fat-sparer, 
alcohol  itself  is  consumed  and  yields  heat  and  energy  to  the  body; 
it  is,  therefore,  to  a  certain  degree  a  food.  Alcohol  is  usually  con- 
sumed in  the  shape  of  champagne,  beer,  wine,  whisky,  brandy  or 
other  concentrated  spirituous  liquor.  The  general  effect  of  alcohol 
in  small  quantities  and  in  not  too  concentrated  form  on  gastric 
digestion  is  to  stimulate  secretion;  but  large  quantities  and  the 
concentrated  drinks  (liquors)  retard  digestion. 


INSTRUCTINC,  THE  PATIENT  169 

Tea  and  Coffee. — Coffee  stimulates  the  secretion  of  the  gastric 
glands  and  increases  the  peristaltic  movements  of  the  intestine. 
Tea  has  a  constipating  effect  on  account  of  the  large  amount  of 
tannic  acid  it  contains,  and  in  animal  experiments  it  retards  the 
secretion  of  acid  and  delays  the  peptonization  of  protein  substances. 
Coffee  should  be  forbidden  in  most  cases  of  gastric  disease.  Very 
weak  tea,  on  the  contrary,  may  be  taken  with  advantage,  especially 
if  used  as  a  vehicle  for  milk  or  other  nutritive  materials.  In  health, 
however,  there  is  no  reason  for  apprehending  danger  to  the  race 
at  large  from  coffee-drinking.  Coffee-drinking  has  not  affected 
Americans  to  any  appreciable  degree,  though  coffee  has  been  the 
almost  universal  beverage  for  many  decades.  The  life  insurance 
companies,  constantly  warring  against  everything  that  tends  to 
shorten  life,  are  silent  in  regard  to  coffee  as  a  beverage.  The  experi- 
ments of  Chase  on  three  normal  individuals  who  were  not  addicted 
to  tea  or  coffee  show  that  when  taken  with  meals,  in  the  amounts 
ordinarily  used,  these  beverages  do  not  retard  either  salivary  or 
peptic  digestion.  It  has  been  found  that  salivary  digestion  is 
aided  slightly  by  tea.  Both  tea  and  coffee  may  act  as  mild  stim- 
ulants to  gastric  secretion;  the  digestive  power  of  the  secretions, 
however,  is  not  augmented,  but,  on  the  other  hand,  neither  is  it 
impaired,  as  in  the  use  of  whisky.  Therefore,  as  a  stimulant  to 
gastric  secretion,  tea  or  coffee  would  seem  preferable  to  whisky. 
A  great  deal  has  been  said  about  the  deleterious  effects  of  tea  and 
coffee  on  the  stomach.  Apart  from  their  stimulating  effect  on  the 
central  nervous  system,  if  properly  made  and  not  too  strong,  their 
effect  on  digestion  is  almost  neutral. 

Cocoa. — Cocoa  possesses  much  higher  nutritive  value  than  tea 
or  coffee.  It  does  not  stimulate  gastric  digestion,  and  prepared 
with  either  water  or  milk  it  is  a  proper  beverage  for  patients  with 
stomach  disease.  Preparations  of  cocoa  from  which  the  oil  has 
been  expressed,  and  which  have  not  been  treated  with  alkalis, 
are  to  be  recommended.  Chocolate  prepared  by  admixture  of 
sugar  and  spices  is  not  so  easily  digested.  It  contains  a  larger 
proportion  of  fat  and  carbohydrates,  and  may  therefore  give  rise 
to  fermentation  and  the  formation  of  acid. 

Tobacco. — The  use  of  tobacco  in  any  form  is  to  be  interdicted 
in  all  cases  of  stomach  disease  because,  clinically,  it  has  often 
proved  to  be  the  cause  of  chronic  gastritis  and  its  sequela?.  Nico- 
tin  may  reduce  the  peristaltic  motions  of  the  stomach  in  conse- 
quence of  its  paralyzing  effect  on  the  vagus.  Tobacco  may  cause 
hyperacidity  in  the  empty  stomach.  Smoking  after  meals  induces 
salivation,  and  when  the  saliva  is  swallowed  the  acid  secretion  of  the 
stomach  becomes  neutralized. 

Instructing  the  Patient. — The  patient  must  be  definitely  instructed 
in  regard  to  what  articles  of  diet  are  permissible  and  what  are  not. 
Printed  schedules  are  frequently  provided  for  this  purpose.     The 


170  DIET  IN  GASTRIC  DISEASES 

allowable  and  the  forbidden  foods  are  all  enumerated  on  these,  and 
those  unsuitable  for  the  patient  are  crossed  off.  The  physician 
should  aim  at  avoiding  unnecessary  monotony  in  dietary  arrange- 
ments. If  possible,  food  luxuries  and  spices  should  be  permitted 
to  such  an  extent  as  to  render  the  prescribed  diet  relishable. 

It  is  quite  proper,  indeed  necessary,  to  give  exact  counsel  regard- 
ing the  quantities  of  food  to  be  taken;  and  the  physician  should 
not  confine  himself  to  such  general  measurements  as  spoonfuls,  cups, 
and  wine  glasses,  the  standards  of  which  vary  so  widely.  The 
quantity  is  more  accurately  specified  in  grams,  as:  Of  fruit  pre- 
serves, the  portion  for  a  patient  with  gastric  disease  should  not 
exceed  150  grams  (five  ounces).  Hints  regarding  the  mode  of 
preparation  of  food  must  likewise  be  carefully  given — e.  g.,  whether 
meat  should  be  eaten  raw,  boiled,  or  roasted;  in  what  form  and 
state  of  subdivision  the  various  foods  are  to  be  taken  (puree, 
mashed,  etc.);  to  what  extent  fats  and  spices  may  be  employed  in 
the  preparation  of  the  dishes;  and  how  strong  tea  or  coffee  may 
be  made. 

It  is  quite  essential,  too,  to  impress  upon  the  patient  the  number 
of  meals  to  be  taken,  and  at  what  hours.  The  rule  is,  light  meals 
at  frequent  intervals.  This  holds  good  particularly  in  cases  of 
atony,  dilatation,  and  pyloric  stenosis,  because  in  such  conditions 
large  quantities  are  very  difficult  to  manage.  In  some  cases  where 
hypersecretion  is  a  feature  the  intervals  between  meals  should  be 
extended  in  order  to  provide,  if  possible,  adequate  periods  of  rest 
for  the  irritated  gastric  mucous  membrane.  Deviations  from  the 
usual  dining  schedule  should  be  as  infrequent  as  possible.  Irregu- 
larity in  eating  is  apt  to  prolong  the  stay  of  the  food  in  the  stomach. 
The  patients  should  not  retire  earlier  than  two  hours  after  par- 
taking of  the  evening  meal.  Mastication  and  oral  digestion  are 
of  the  utmost  importance.  Only  when  these  are  accomplished  in 
a  correct  manner  is  it  possible  for  the  food  to  reach  the  stomach 
in  such  a  condition  as  to  facilitate  its  penetration  and  solution  by 
the  digestive  juices. 

Patients  should  eat  slowly.  Prolonged  mastication  not  only 
thoroughly  insalivates  the  food,  but  has  a  favorable  and  stimulating 
effect  on  the  secretion  of  the  gastric  juice.  During  the  meal  no 
strain  should  be  put  upon  the  mind,  consequently  reading  while 
eating  is  to  be  forbidden.  Anger,  excitement,  and  irritating  dis- 
cussions must  be  avoided  at  the  table.  When  the  patient  has  no 
appetite  he  is  not  to  be  coaxed  or  harassed  into  taking  food. 

Beverages  in  moderate  quantities  are,  as  a  rule,  without  evil 
influence  in  health.  In  gastric  diseases,  however,  drinking  during 
the  meals  is  probably  better  omitted. 

Immediately  after  eating,  fatiguing  bodily  or  mental  exercise 
should  not  be  taken.  Vigorous  bodily  exertions  at  such  a  time 
produce,  even  in  health,  sensations  of  discomfort;  in  disease  they 


INSTRUCTING  THE  PATIENT  171 

are  positively  harmful,  as  they  are  liable  to  diminish  the  secretion 
of  hydrochloric  acid  in  the  stomach.  A  patient  with  gastric  dis- 
ease should  lie  down  after  eating,  and  on  his  right  side,  since  in 
that  position  the  stomach  is  emptied  more  rapidly.  The  clothing 
should  not  bind  the  stomach. 

It  is  an  open  question  whether  patients  should  sleep  after  dinner; 
in  the  majority  of  cases  this  may  be  left  to  the  patient  himself. 
The  percentage  of  acid  in  the  stomach,  and  the  motility  of  that 
organ,  are  said  to  be  diminished  during  sleep.  These  facts  must 
be  borne  in  mind  when  considering  the  advisability  of  either  for- 
bidding or  permitting  the  after-dinner  nap. 


CHAPTER  VII. 

DIET  IN  INTESTINAL  DISEASES. 

Regulation  of  the  diet  plays  the  chief  role  in  all  therapeutic 
measures  employed  in  the  treatment  of  intestinal  diseases.  Broadly 
speaking,  the  various  affections  of  the  bowels  are  characterized 
by  either  diarrhea  or  constipation.  For  this  reason  the  dietary 
instructions  must,  as  a  rule,  be  formulated  with  special  regard  to 
the  constipating  or  laxative  effect  of  the  selected  foods. 

CONSTIPATING  DIET. 

A  constipating  diet  is  one  which  will  not  stimulate  peristalsis 
of  the  intestine,  either  mechanically  or  chemically;  it  does  not 
irritate  the  mucous  membrane,  muscles  or  nerves  of  the  intestine. 
Food  that  is  imperfectly  acted  upon  by  the  secretions  of  the  stomach 
and  intestine,  resulting  in  fermentation  and  putrefaction,  should 
be  interdicted,  since  the  products  of  fermentation  and  putrefaction 
are  great  stimulants  of  peristalsis.  The  patient  must  be  instructed 
to  eat  sparingly,  so  as  to  limit  the  elimination  of  bulky  or  waste 
products  which  excite  normal  peristalsis.  Foods  should  be  taken 
which,  on  absorption,  leave  little  or  no  residue  of  which  the  intestine 
has  to  rid  itself.  Astringent  foods  and  beverages  inhibit  both 
normal  and  abnormal  secretion,  inducing  constipation.  Small  and 
frequent  meals  prevent  overdistention  and  retard  peristalsis. 

A  constipating  diet,  which  in  effect  is  equivalent  to  a  non-irri- 
tating diet,  must  be  considered  in  the  following  conditions  if  they 
are  associated  with  diarrhea,  viz. :  Acute  and  chronic  catarrh  of  the 
small  and  the  large  intestine,  chronic  diarrhea  in  its  various  forms, 
hemorrhages  from  the  bowel,  intestinal  ulcers,  malignant  neoplasms, 
and  stenoses.  The  time  has  passed  when  every  case  of  diarrhea 
could  be  classed  as  "intestinal  catarrh."  It  is  of  the  utmost  impor- 
tance that  an  exact  diagnosis  be  established  before  dietetic  measures 
are  instituted.  Today  we  must  in  every  case  determine  exactly 
the  work  done  by  the  intestine,  by  examining  the  feces.  In  the 
opinion  of  the  author  the  method  of  determining  the  physiologic 
activity  of  the  intestine,  inaugurated  by  Schmidt  and  Strasburger,1 
and  culminating  in  the  well-known  test  diet,  deserves  to  be  pre- 
ferred to  all  other  methods.  It  is  a  fact  that  all  the  attempts — 
and  there  have  been  many  of  them — to  modify  the  practice  of 

1  Schmidt  and  Strasburger:     Die  Fazes  des  Menschen,  Berlin,  1910. 


CONSTIPATING  DIET  173 

Schmidt  and  Strasburger  have  been  unsuccessful;  they  do  not 
represent  any  improvement  in  method.  Macroscopic,  microscopic 
and  chemical  examination  of  the  feces  after  Schmidt's  test  diet1 
must  be  followed  out  in  its  entirety  before  the  rules  for  a  rational 
dietary  regimen  can  be  laid  down.     (See  Chapter  IV.) 

By  means  of  examination  of  the  feces  we  are  frequently  able 
to  locate  the  pathologic  process  in  the  large  or  the  small  intestine 
— a  very  important  differentiation  in  its  bearing  on  dietary  restric- 
tions. We  can  also  by  this  means  obtain  information  as  to  whether 
some  particular  constituent  of  the  food  (meat,  carbohydrate, 
fat,  connective  tissue)  is  exceptionally  ill-digested.  Moreover, 
examination  of  the  material  of  a  single  evacuation  will  show  whether 
protein  putrefaction  or  carbohydrate  fermentation  is  present.  The 
knowledge  afforded  by  analysis  of  the  feces  has  to  be  carefully 
borne  in  mind  in  planning  the  patient's  regimen,  for  upon  it  depends 
the  question  of  increasing  or  decreasing  the  amount  of  protein, 
carbohydrates  or  fats  to  be  taken  in  any  particular  case,  or  the 
adoption  of  a  different  and  easily  digested  diet.  It  is  particularly 
important  to  establish  positively  whether  there  is  putrefaction  or 
fermentation.  It  is  possible,  by  making  a  change  in  the  diet  in 
these  cases,  to  create  a  nutritional  medium  in  W'hich  the  harmful  or 
undesirable  bacteria  will  be  unable  to  multiply  with  their  usual 
rapidity.  The  examination  of  the  bacterial  flora  of  the  intestinal 
tract  with  this  end  in  view  is  not  merely  of  theoretical,  but  of 
practical  importance.  In  the  large  majority  of  cases  the  treatment 
to  be  sought  is  the  one  which  most  effectively  combats  the  putre- 
factive processes  within  the  intestine. 

It  is  now  know^n  that  the  fluidity  of  diarrheal  discharges  is  due 
to  the  transudation  of  serum  into  the  intestinal  canal.  This  serum, 
as  wTell  as  other  products  derived  from  the  intestinal  wall  (mucus, 
pus,  blood),  is  particularly  liable  to  decomposition;  it  "putrefies" 
much  more  readily  than  protein  of  the  food  wrhich  may  have 
escaped  digestion.  For  this  reason,  in  all  chronic  diseases  of  the 
intestine  (catarrhs,  ulcers,  ulcerating  malignant  tumors)  there 
is  found  a  decomposing  stool,  wrhich  may  be  recognized  as  such 
by  analysis  of  the  test-diet  feces  (decomposition  in  the  incubator 
test,  with  a  change  to  an  alkaline  reaction,  and  occasionally, 
though  more  rarely,  the  demonstration  of  soluble  protein).  Cases 
of  putrefaction  are  to  be  differentiated  from  those  of  pure  carbo- 
hydrate fermentation — that  is,  from  the  cases  of  chronic  intestinal 
disease  in  which  fermentation  of  carbohydrates  predominates 
(recognizable  by  acid  fermentation  in  the  incubator  test).  These 
latter  conditions  are  comparatively  rare.     (See  page  116.) 

Gastrogenic  diarrheas,  especially  when  existing  for  a  long  time, 
are  quite  often  associated  with  catarrhal  conditions  of  the  intes- 

1  Adolf  Schmidt :  The  Test  Diet  in  Intestinal  Diseases,  translated  by  Charles  D. 
Aaron.     Philadelphia,  1909. 


174  DIET  IN  INTESTINAL  DISEASES 

tinal  mucous  membrane,  and  in  these  cases  the  intestinal  contents 
incline  more  toward  putrefaction.     (See  Chapter  XXXVIII.) 

From  these  facts  we  must  conclude  that  in  the  majority  of 
intestinal  diseases  accompanied  by  diarrhea,  that  is  to  say  in  the 
overwhelming  majority  of  all  patients  suffering  from  intestinal 
ailments,  we  must  insist  upon  a  diet  opposed  to  putrefaction. 

A  diet  may  act  antiseptically  because  of  either  its  chemical  or 
its  mechanical  constitution.  From  the  chemical  viewpoint,  in  an 
antiseptic  diet  the  carbohydrates  must  predominate.  We  should 
either  eliminate  entirely  protein  articles  of  diet,  especially  at  first 
and  in  grave  cases,  or  restrict  them  to  those  protein  substances 
which  are  most  easily  soluble  and  most  readily  digested.  Where 
both  carbohydrates  and  protein  bodies  are  in  the  same  patient 
subjected  to  decomposition,  the  putrefaction  of  the  protein  is 
retarded  as  long  as  there  are  present  carbohydrates  capable  of 
fermentation.  From  the  mechanical  standpoint  an  entirely  non- 
irritating  diet  must  be  demanded.  It  is  evident  that  a  diet  that 
irritates  the  bowel  as  little  as  possible  will  diminish  the  secretion 
of  easily  decomposable  serum,  mucus,  and  pus,  and  will  thus 
contribute  to  the  diminution  of  the  processes  of  decomposition. 
This  non-irritating  intestinal  diet  is  obtained  by  the  most  minute 
subdivision  of  all  articles  of  diet,  the  removal  of  all  coarse  residues 
(cellulose,  connective  tissue)  from  the  food,  and  the  avoidance  of 
all  additions  of  irritating  spices.  It  is  by  no  means  an  easy  matter 
to  arrange  a  menu  conforming  to  all  these  requirements  and  at 
the  same  time  giving  taste,  flavor,  and  variety.  The  best  anti- 
septic food,  both  chemically  and  mechanically  considered,  is 
afforded  by  the  mucoid  soups — which  should  therefore  be  em- 
ployed in  all  grave  cases.  The  mucoid  soups  are  prepared  from 
oatmeal,  rice  meal,  wheat  starch,  rice  starch,  potato  starch,  and 
corn  starch.  The  grains,  grits  or  flakes  are  boiled  four  to  six 
hours  with  water,  passed  through  a  fine  sieve,  and  again  brought 
to  the  boiling-point- — when  they  are  ready  for  use.  The  flours, 
beaten  up  in  a  small  quantity  (|  liter — 4  ounces)  of  cold  water, 
are  added  to  \  liter  (1  pint)  of  boiling  water  and  boiled  four  to 
six  hours.  By  proper  additions  of  milk,  cream  and  butter  these 
soups  are  rendered  palatable  and  nutritious.  In  cases  of  lesser 
severity,  soups  _  may  be  given  prepared  from  other  leguminous 
flours,  from  tapioca,  sago,  ground  rice,  dried  rolls,  or  zwieback 
and  cocoa. 

Antiputrefactive  Diet.' — Of  the  foods  containing  protein  and  acting 
antiseptically,  milk  deserves  particular  attention.  A  constant 
endeavor  should  be  made  to  accustom  the  patient  to  it.  Milk, 
though  it  possesses  great  nutritional  value,  requires  for  its  assimila- 
tion comparatively  little  digestive  work.  It  has  also  been  ascer- 
tained that  milk,  of  all  the  foods  containing  protein,  yields  the 
smallest  proportion  of  decomposition  products. 


ANTIPUTREFACTIVE  DIET  175 

Among  the  medical  profession  as  well  as  the  laity,  milk  is  fre- 
quently looked  upon  with  disfavor  as  an  article  of  diet  in  cases  of 
gastric  disease,  under  the  mistaken  impression  that  it  is  difficult 
of  digestion.  It  is  true  that  milk  occasionally  causes  diarrhea  and 
sometimes  constipation,  both  in  health  and  in  those  suffering  from 
intestinal  disorders.  This  is,  strange  to  say,  the  case  when  the  milk 
is  taken  pure  (fresh  or  boiled)  and  without  admixture.  These 
undesirable  effects  may  be  avoided  by  adding  to  the  milk  minute 
quantities  of  rice,  oatmeal,  crackers,  or  other  food;  in  the  course  of 
a  few  days  after  this  change  is  instituted  the  milk  will,  on  ingestion, 
be  assimilated  without  difficulty.  Schmidt  is  of  the  opinion  that 
in  cases  in  which  the  patient  has  not  been  drinking  any  milk  for  a 
long  time,  the  intestine  and  its  vegetation  may  need  a  certain  time  to 
adapt  themselves  to  the  new  food.  As  yet  no  satisfactory  explana- 
tion has  been  advanced  for  those  rare  cases  in  which  milk  always 
gives  rise  to  diarrhea  by  its  peculiar  influence  on  the  peristaltic 
movements.  The  cause  cannot  be  found  in  the  ingredients  of  the 
milk.  Milk  is  the  mildest  and  least  irritating  of  all  foods,  being 
digestible  even  by  the  tender  digestive  organs  of  the  newborn  infant. 
When  milk  is  not  well  borne,  it  may  be  assumed  that,  because  of 
certain  individual  peculiarities  or  pathologic  conditions,  it  is  easily 
decomposed,  and  that  the  intestine  is  irritated  by  such  decompo- 
sition products;  or  the  intestine,  being  in  a  state  of  hyperirritability, 
is  abnormally  sensitive  toward  the  decomposition  products  of  milk 
digestion.  It  is  possible  that  this  peculiar  irritating  effect  of  the  milk 
may  be  brought  about  by  a  rapid  fermentation  of  the  carbohydrates 
(milk-sugar).  Of  all  the  varieties  of  sugar,  milk-sugar  most  readily 
yields  to  fermentation  within  the  bowel.  It  must,  however,  be  dis- 
tinctly understood  that  these  disturbances  after  the  ingestion  of  milk, 
though  undoubtedly  occurring  in  isolated  cases,  are  by  no  means  of 
so  great  frequency  as  is  generally  supposed,  even  in  patients  with 
intestinal  disease.  Credit  should  not  be  given  unhesitatingly  to  the 
statements  of  certain  patients  that  they  are  unable  to  digest  milk, 
for  on  closer  investigation  it  is  usually  found  that  the  milk  is  per- 
fectly assimilated.  For  these  reasons  Schmidt  has  made  milk  an 
integral  constituent  of  the  test  diet  he  recommends  (vide  infra). 

Xo  cause,  therefore,  appears  for  abandoning  milk  in  the  feeding 
of  patients  suffering  from  intestinal  disease;  the  more  so  since  it  is 
no  easy  matter  to  replace  this  excellent  and  easily  digestible  food 
by  other  substances.  The  possibility,  however,  that  disturbances 
may  occasionally  take  place  in  the  digestion  of  this  all  but  ideal 
food,  should  induce  us  to  exercise  great  care  and  circumspection 
in  the  administration  of  a  milk  diet.  The  best  guide  is  the  degree 
of  digestibility  of  the  milk  administered  during  the  test  diet  for 
analytic  purposes.  Our  practice,  therefore,  consists  at  first  in 
the  giving  of  small  quantities  of  milk  as  an  addition  to  other  foods. 
Such  foods  are  acorn-cocoa,  cocoa,  chocolate,  and  various  muci- 


176  DIET  IN  INTESTINAL  DISEASES 

laginous  foods  prepared  from  rice,  tapioca,  barley,  oats,  or  different 
kinds  of  flour.  Milk  may  also  be  employed  generously  as  a  con- 
stituent of  the  numerous  kinds  of  mucilaginous  and  flour  soups, 
mushes,  puddings,  and  purees.  With  the  exercise  of  care  in  the 
administration  of  the  milk,  beginning  with  |  liter  (|  pint)  per  day, 
the  quantity  may  be  rapidly  increased  to  \  liter  (1  pint)  and 
even  more.  Should  increased  peristaltic  movements  be  noticeable 
dining  the  first  two  or  three  days  (the  occasional  constipating 
effect  of  milk  would  be  rather  welcome  in  the  cases  under  discus- 
sion), this  should  not  to  be  regarded  as  a  reason  for  discontinuing 
the  milk,  for  tolerance  usually  becomes  established  in  a  few  days. 
If  it  should  be  necessary  to  discontinue  the  milk,  as  may  occasionally 
be  the  case,  it  is  advisable  to  insist  upon  repeated  trials  as  to  its 
toleration.  Milk  should  be  used  most  carefully  in  all  cases  of  well- 
marked  catarrh  of  the  small  intestine  and  in  cases  of  ulceration 
(tuberculosis),  for  in  these  diseases  the  irritating  effects  are  most 
frequent;  but  it  may  be  given  in  larger  quantities  when  the  disease 
is  located  lower  down  in  the  bowel.  In  certain  chronic  catarrhs 
of  the  large  intestine,  milk  frequently  has  a  very  beneficial  effect. 

Adolf  Schmidt  has  drawn  attention  to  another  means  employed 
for  diminishing  the  irritating  effects  of  milk.  He  reasoned,  from 
the  belief  that  the  irritating  effects  of  milk  in  many  cases  are  due 
to  its  abnormal  facility  of  becoming  decomposed,  or  to  the  abnor- 
mally increased  sensitiveness  of  the  intestinal  mucous  membrane 
toward  the  decomposition  products  of  the  milk,  that  the  addition 
of  salicylic  acid  to  the  milk,  by  counteracting  the  tendency  to 
decomposition,  would  render  the  milk  tolerable.  For  this  purpose 
he  proceeded  as  follows:  The  daily  portion  of  the  milk  intended 
for  consumption  was  boiled  with  0.2  Gm.  (3  grains)  of  pine  salicylic 
acid  per  liter  (quart).  First  the  proper  quantity  of  salicylic  acid 
was  triturated  with  a  little  milk  in  a  mortar,  and  only  when  minutely 
subdivided  was  it  added  to  the  total  quantity  (1  liter).  It  has 
been  shown  that  milk  prepared  in  this  manner  is  well  borne  in  cases 
in  which  chronic  hypersensitivenes  toward  pure  milk  is  present, 
not  only  in  adults,  but  also  in  children.  The  addition  of  salicylic 
acid  removes  the  deleterious  qualities  of  the  milk  without  inter- 
fering with  its  good  qualities.  For  the  same  purpose  we  frequently 
add  one  or  two  tablespoonfuls  of  lime-water  to  a  glass  of  milk. 
Salicylic  acid,  however,  is  certainly  more  effective. 

In  the  feeding  of  young  patients  the  milk  should  be  adminis- 
tered only  after  being  boiled,  in  order  to  prevent  the  accidental 
introduction  of  pathogenic  germs  (typhoid,  tuberculosis,  diphtheria, 
scarlet  fever).  This  precaution  does  not  appear  to  be  necessary, 
however,  in  the  case  of  adults. 

Milk  may  be  replaced  by  any  of  the  preparations  of  milk  fully- 
described  in  Chapter  VI — pegnin  milk,  milk  with  the  addition  of 
cream  and  milk-sugar,  buttermilk,  etc.    Special  attention  should 


.WTII'l  TREFACTIVE  DIET  177 

be  given  to  three-day  kefir,  which  acts  as  an  astringent,  and  par- 
ticularly to  yoghurt,  the  disinfecting  effecl  of  which,  together 
with  its  great  nutritional  importance,  has  already  Ween  fully  con- 
sidered.    (See  page  162.) 

Should  it  be  desirable  to  administer  other  protein  substances 
besides  milk — and  in  severe  cases  it  is  sometimes  not  only  desirable 
but  necessary — a  protein  should  be  selected  that  is  non-irritating 
and  antibacterial.  Among  the  artificial  food  preparations,  those 
containing  casein  in  small  quantities  (nutrose,  plasmon)  are  de- 
serving of  special  consideration.  It  is  a  question  whether  in  severe 
cases  gelatin  should  not  be  used  more  extensively  than  it  is  today. 
Gelatin  belongs  to  the  nitrogenous  group  of  substances;  it  possesses 
many  of  the  aminoacids  in  common  with  protein,  and  is  easily 
converted  into  peptones  by  the  digestive  ferments.  Gelatin  does 
not  contain  either  the  tryptophan  or  the  tyrosin  radicals  that  are 
always  found  in  protein,  and  for  this  reason  does  not  readily  decom- 
pose. Tryptophan  in  the  process  of  decomposition  forms  skatol, 
indol,  and  other  irritating  products,  while  tyrosin  evolves  several 
varieties  of  phenol,  which  in  case  of  excessive  putrefaction  may  be 
absorbed,  producing  toxic  symptoms.  Gelatin  is  easily  digested, 
and  readily  absorbed  by  the  intestinal  mucous  membrane. 

Recently  we  have  learned  the  value  of  gelatin  in  certain  gastro- 
intestinal diseases.  Murlin  found  that  under  certain  conditions 
as  much  as  63  per  cent,  of  the  total  nitrogen  necessary  for  the 
body  could  be  supplied  in  the  form  of  gelatin.  Herter  considers 
gelatin  a  valuable  food,  possessing  the  property  of  inhibiting 
certain  forms  of  intestinal  decomposition.  He  calculates  that 
one  ounce  of  gelatin  will  yield  120  calories.  This  amount  may  be 
easily  added  to  milk  and  may  thus  at  times  be  of  the  greatest  impor- 
tance for  nutrition.  It  has  been  found  that  certain  microorganisms 
(Bacillus  bifidus  and  Bacillus  infantilis),  commonly  found  in  the 
intestinal  canal  in  certain  gastro-intestinal  diseases,  will  not  grow 
on  a  gelatin  medium  outside  of  the  body,  while  on  a  carbohydrate 
or  protein  medium  they  multiply  rapidly.  This  is  a  logical  reason 
why  gelatin  should  be  used  more  than  it  is  in  intestinal  diseases. 
(See  page  161.) 

The  value  of  this  non-irritating  diet  is  strengthened  by  the  fact 
that  the  volume  of  the  food  is  small.  This  circumstance  permits  as 
great  an  increase  in  the  percentage  of  calories  contained  in  the  food 
as  it  is  possible  to  furnish — a  result  that  is  attained  by  the  addition 
of  cream  and  the  best  kind  of  butter.  Additions  of  beef  bouillon, 
meat  extract,  maggi,  and  common  salt,  in  moderate  quantities,  are 
allowable  and  even  imperative,  not  only  for  their  flavor,  but  also 
for  their  stimulating  effect  on  the  appetite.  Besides  this  the  astrin- 
gent effect  of  some  articles  of  food  should  be  utilized,  as  for  example 
tea,  acorn-cocoa,  claret  rich  in  tannin  (especially  the  Greek  camerite ) , 
and  particularly  whortleberries.  The  latter  are  given  in  the  form 
12 


178  DIET  IN  INTESTINAL  DISEASES 

of  decoction,  whortleberry  juice,  whortleberry  thick  soups,  whortle- 
berry wine,  and  whortleberry  gelatin.  The  skins  and  the  seeds 
must  be  entirely  removed.  Blackberries,  also  rich  in  tannin,  may 
be  employed  in  a  similar  manner. 

Such  a  diet  will  always  assist  in  accomplishing  the  desired  end, 
which  is  to  inhibit  or  to  diminish  well-marked  processes  of  decom- 
position. It  is  possible  to  diminish  the  number  of  bacteria  in  the 
feces  by  the  use  of  antibacterial  soups,  milk  diet,  and  salicylic 
milk.  Under  this  regimen,  should  pure  carbohydrate  fermentation 
develop,  which  could  be  ascertained  by  an  analysis  of  the  feces, 
no  harm  would  be  done.  It  would  be  preferable  to  the  putrefaction 
of  protein,  and  could  be  promptly  inhibited  by  limiting  the  supply 
of  carbohydrates  or  by  the  use  of  salicylic  milk.  When  in  severe 
cases  improvement  begins,  other  articles  of  food  are  added  gradually. 
It  must,  however,  be  stated  that  extreme  caution  should  be  ob- 
served, and  the  addition  of  more  food  should  take  place  in  the 
most  gradual  manner.  All  food  must  be  of  the  aseptic  variety 
and  free  from  all  irritating  properties;  otherwise  relapses  are 
apt  to  occur.  The  basis  of  the  diet  will  therefore  consist  of  soups 
and  milk,  the  quantity  of  which  may  be  gradually  increased  and  a 
somewhat  greater  variety  permitted.  In  this  respect  foods  con- 
taining carbohydrates  are  to  be  considered  first,  the  additions 
consisting  of  zwieback,  crackers,  and  stale  white  bread,  all  of  which 
must  be  well  softened  and  thoroughly  masticated.  The  soups  are 
thickened  with  thoroughly  cooked  rice  or  browned  flour.  The  quan- 
tity of  bouillon,  and  especially  the  quantity  of  butter,  may  be 
increased — the  latter,  of  course,  only  in  those  cases  in  which  the 
feces  do  not  contain  abnormally  large  quantities  of  fat.  Later, 
soups  may  be  gradually  omitted;  they  may  be  replaced  by  various 
kinds  of  mushy  foods  prepared  from  rice,  sago,  oat  flakes,  tapioca, 
various  flours  with  the  addition  of  butter,  milk,  cream,  whipped 
cream,  claret,  or  whortleberry  wine  with  sugar.  Frequently  the 
addition  of  sugar  must  be  restricted,  and  occasionally  saccharin 
may  be  used.  As  the  case  progresses,  light  flour  dishes  or  noodles 
should  be  given.  Gradually  and  carefully  vegetables  may  be 
added;  these,  however,  must  be  well  ground  up  and  forced  through 
a  sieve— e.  g.,  small  quantities  of  mashed  potatoes  prepared  with 
plenty  of  butter  and  eggs;  puree  of  white  beans,  peas,  cauliflower, 
or  artichokes,  with  the  addition  of  butter,  bouillon,  and  milk. 
When  the  compact  form  of  the  feces  indicates  that  transudation 
of  serum  through  the  mucous  membrane  has  ceased,  and  when 
mucus  is  being  excreted  in  small  quantities  only,  and  the  incubator 
test  shows  that  there  is  no  decomposition  in  the  feces,  then  no  fear 
need  be  entertained  that  putrefactive  processes  will  be  reestablished 
by  the  careful  resumption  of  proteins.  Jellies,  being  easy  of  diges- 
tion, should  be  allowed  first — meat  jelly,  milk  jelly,  whortleberry 
jelly.     Then  the  artificial  albumino-casein   preparations   may  be ' 


ANTIPUTREFACTIVE  DIET  179 

given  in  larger  quantities  as  adjuncts  to  soups,  etc.  When  these 
are  well  tolerated,  eggs  can  be  added.  Eggs  may  be  taken  in  a 
great  variety  of  preparations,  as  yolk  of  eggs  in  beef-tea  and  soups, 
the  whole  egg  in  omelets  or  light  puddings,  as  a  component  of  jellies 
and  pies,  or  beaten  up  to  a  froth  with  claret  and  a  little  sugar 
added.  Caution,  however,  is  always  necessary  with  eggs,  since 
patients  suffering  from  intestinal  disease  are  apt  to  be  singularly 
intolerant  of  them.  Later,  small  quantities  of  tender  meat  may  be 
allowed  (squab,  breast  of  chicken,  and  tender  lean  beef),  all  of 
which  must  be  well  cut  up  and  chopped  or  forced  through  the 
very  finest  of  hair  sieves.  The  meat  may  either  be  given  as  such 
or  stirred  into  soups.  Soups  prepared  with  calf's  brain  (demenbran- 
ated)  and  veal  sweetbread  may  be  given.  Schmidt  demands, 
and  justly  so,  the  exclusion  of  raw,  smoked  or  pickled  meat  from 
the  diet  of  patients  suffering  from  intestinal  diseases,  not  only 
because  of  the  toughness  of  the  material,  but  particularly  because 
it  may  contain  somewhat  coarse  shreds  of  connective  tissue.  This 
is  particularly  important  in  cases  of  gastrogenic  diarrhea,  for  the 
raw  or  smoked  connective  tissue  is  not  dissolved  by  an  achylic  or 
subacid  and  muscularly  weak  stomach.  It  has  been  found  that 
raw  connective  tissue  is  not  always  dissolved  by  normal  or  even 
hyperacid  stomachs.  Reaching  the  intestine  in  an  undigested 
condition,  the  connective  tissue  is  not  dissolved  at  all,  but  con- 
stitutes a  coarse  mechanical  irritant  to  the  intestinal  mucous 
membrane,  especially  if  the  latter  is  diseased.  Besides,  it  becomes 
a  breeding  place  for  a  vast  number  of  microorganisms  of  putre- 
faction and  fermentation.  Raw  beef  is  only  to  be  given  when 
scraped  carefully  with  the  spoon  from  the  whole  cut  of  a  tender 
fillet;  in  such  scraped  meat  the  amount  of  connective  tissue  is 
reduced  to  the  smallest  possible  proportion. 

At  this  period  the  diet  should  approximate  the  test  diet  of  Schmidt 
(page  112).  To  this  diet  when  necessary  some  claret,  a  little  bouillon 
and  at  night  thin  slices  of  cold  roast  veal  may  be  added. 

The  Schmidt  diet  is  an  example  of  a  diet  non-irritating  to  the 
intestine,  and  as  such  valuable  not  only  diagnostically  but  thera- 
peutically. It  may  in  many  cases  be  made  the  basis  of  the  general 
diet,  to  be  varied  as  occasion  demands  by  increasing  or  diminishing 
the  different  articles. 

In  connection  with  this  diet  green  vegetables  are  permitted  in 
small  quantities  when  the  cellulose  they  contain  does  not  act  as 
an  irritant.  Only  those  which  may  be  easily  cut  up  into  very  fine 
particles  are  allowed  (spinach,  cauliflower,  green  lettuce,  ends  of 
asparagus).  As  the  improvement  continues  and  the  last-mentioned 
foods  are  well  tolerated,  the  consumption  of  larger  quantities  of 
all  these  foods  is  gradually  permissible,  and  later  the  coarser  ones 
need  not  be  cut  up  as  minutely  as  before.  Then  boiled  fruit  is 
allowed,  at  first  in  the  form  of  jam  (apples,  pears).    The  skins  and 


180  DIET  IN  INTESTINAL  DISEASES 

seeds  must  be  forbidden  for  a  long  time,  also  those  varieties  of 
fruit  which  contain  much  acid,  since  the  fruit  acids  may  act  as 
purgatives.  The  object  of  this  gradual  change  in  the  character  of 
the  food  is  the  rehabituation  of  the  intestine  to  the  usual  mixed 
diet  as  tolerated  without  any  discomfort  in  health.  This  desider- 
atum is,  unfortunately,  not  always  attainable  in  chronic  cases, 
especially  in  chronic  catarrhs,  which  are  often  very  obstinate.  In 
such  cases  the  diet  should  be  kept  under  control  and  should  con- 
sist of  non-irritating  foods  for  the  remainder,  of  the  life  of  the 
patient. 

Regarding  beverages,  warmth  of  the  liquid  must  be  especially 
advised  in  grave  cases  in  which  the  diet  has  been  carefully 
arranged.  Warm  drinks  have  a  calmative  effect  on  the  mucous 
membrane  of  the  intestine.  Various  kinds  of  teas  are  given,  as 
chamomile,  anise-seed,  valerian,  and  peppermint,  with  or  without 
the  addition  of  milk,  claret,  rum,  or  cognac.  Besides  these,  there 
may  be  given  boiled  water  with  claret,  pure  milk,  claret,  and  whortle- 
berry wine.  Lemonades  and  fruit  juices  are  only  to  be  given  during 
convalescence.     Ice-cold  drinks  are  to  be  positively  interdicted. 

Thus  far  the  dietetic  treatment  of  severe  cases  with  diarrhea, 
marked  decomposition,  and  excessive  peristalsis,  has  been  described. 
It  is  evident  that  for  moderate  and  light  cases  the  diet  from  the 
start  need  not  be  arranged  quite  so  carefully.  The  light  cases 
commence  with  a  diet  which  is  equivalent  to  the  one  permitted  in 
severe  cases  during  convalescence.  The  guide  here  also  may  be 
the  tolerance  of  the  intestine  toward  Schmidt's  test  diet.  In  light 
cases  the  test  diet  may  be  given  from  the  beginning  for  therapeutic 
purposes. 

It  is  therefore  essential  to  individualize  the  nutrition  in  the  cases 
of  intestinal  disease  under  discussion,  basing  both  it  and  the  diag- 
nosis on  the  results  of  the  analysis  of  the  feces.  Should  the  stomach 
be  simultaneously  affected,  its  digestive  ability  must  have  atten- 
tion, since  in  many  cases  of  chronic  diarrhea  (gastrogenic  diarrhea) 
the  treatment  of  the  stomach  is  of  greater  importance  than  the 
most  careful  intestinal  diet.  The  same  holds  good  in  cases  of 
nervous  diarrhea.  The  treatment  here  has  to  be  directed  particu- 
larly toward  the  nervous  system.  A  strict  outline  of  diet  cannot 
be  propounded  for  nervous  cases.  Adherence  to  a  non-irritating 
diet  is  often  unnecessary  in  these  cases,  and  may  even  prove  to 
be  harmful.  A  sudden  change  in  the  nervous  cases  frequently 
produces  a  surprisingly  beneficial  effect.  Generally  speaking,  the 
dictum  holds  good  that  we  should  be  more  careful  in  the  diet 
the  higher  up  in  the  intestine  the  disease  is  situated.  The  greatest 
care  is  demanded  in  diseases  of  the  small  intestine;  when  the 
pathologic  process  is  located  in  the  lower  portion  of  the  large 
intestine  it  is  not  necessary  to  be  nearly  so  strict.  The  reason 
for  this  is  that  the  contents  of  the  small  intestine  normally  enter 


ANT1 FERMENTATIVE  DIET  181 

the  large  intestine  in  a  semiliquid  state;  if,  therefore,  the  small 
intestine  functions  properly,  both  it  and  the  large  intestine  are 
protected  to  a  certain  extent  from  mechanical  irritation  by  the 
intestinal  contents;  but  if  the  function  of  the  small  intestine  is 
defective,  irritation  follows,  not  only  to  this  part  of  the  alimentary 
tract,  hut  to  the  large  intestine  as  well.  In  diseases  of  the  large 
intestine,  every  kind  of  food  should  be  avoided  that  cannot  be 
easily  transformed  into  a  semiliquid  mass  in  the  small  intestine 
(connective  tissue,  cellulose),  but  there  is  no  necessity  of  being 
so  particular  about  the  minute  breaking  up  of  the  food  as  in  diseases 
of  the  small  intestine. 

Antifermentative  Diet. — The  antifermentative  diet  stands  in  con- 
trast to  the  antiputrefactive.  It  is  indicated  in  all  cases  in  which 
fermentation  of  the  carbohydrates  causes  acute  or,  particularly, 
chronic  diarrhea,  Such  carbohydrate  fermentation  is  found  occa- 
sionally in  all  chronic  diseases  of  the  intestine,  and  especially 
in  acute  and  chronic  catarrhs  and  in  gastrogenic  diarrhea  when 
the  bacteria  of  fermentation  succeed  in  settling  in  the  intestine 
on  a  favorable  soil  containing  carbohydrates.  The  organisms 
responsible  for  the  fermentation  of  the  carbohydrates  are  the  iodin 
germs,  so  named  by  Schmidt.  They  contain  granules,  and  become 
blue  in  the  presence  of  iodin;  unstained  they  resemble  yeast  cells. 
They  are  probably  identical  with  the  granulobacillus  butyricus  of 
Grasberger.  Thus  there  are  intestinal  catarrhs  and  gastrogenic 
(hyperacidity)  intestinal  disorders  in  which  the  diarrhea  is  not 
associated  with  putrefaction,  but  with  fermentation.  These  latter 
cases,  however,  are  rarer  than  those  in  which  decomposition  of 
protein  predominates. 

A  disease  of  this  kind,  of  rather  frequent  occurrence,  is  the  so- 
called  intestinal  fermentative  dyspepsia  of  Schmidt  and  Stras- 
burger,  which  may  appear  in  the  absence  of  any  organic  lesion 
of  the  intestine  and  when  the  stomach  is  perfectly  normal  (see 
Chapter  XXXVIII).  Fermentative  changes  are  recognized  by  the 
light  greenish-yellow  color,  the  spongy  semifluid  consistency,  and 
the  strongly  acid  reaction  of  the  feces.  In  the  incubator  such  feces 
always  show  an  acid  fermentation  (Plate  VIII,  Fig.  b).  These  cases 
demand  a  careful  regulation  of  the  diet,  as  determined  by  analysis 
of  the  feces.  One  can  also  learn  by  this  analysis  whether  the  bowel  is 
organically  diseased,  or  whether  the  condition  is  due  to  a  pathologic 
stomach.  The  principle  of  the  diet  naturally  consists  in  reducing 
the  amount  of  fermentable  carbohydrates,  or  discontinuing  them 
entirely.  Protein  and  fat  should  be  substituted  and  continued 
until  examination  of  the  feces  shows  that  the  ferments  have  lost 
their  activity.  'When  the  intestine  is  entirely  healthy  no  special 
attention  need  be  given  the  gross  form  of  the  diet ;  it  is  only  neces- 
sary to  supply  a  pure  protein-fat  diet  for  a  certain  length  of  time 
and   then  gradually  administer   the   most   easilv  soluble  or  even 


182  DIET  IN  INTESTINAL  DISEASES 

predigested  carbohydrates  until  tolerance  is  reestablished.  But 
when  there  are  synchronous  organic  intestinal  disturbances,  par- 
ticularly catarrhs,  the  diet  has  to  fulfil  all  the  above  stated  require- 
ments respecting  the  absence  of  irritants  and  the  minute  subdivision 
of  the  food,  in  proportion  to  the  gravity  of  the  pathologic  con- 
dition. Here,  too,  it  will  be  impossible  to  give  protein  and  fat 
exclusively,  because  the  fermentation  process  is  readily  convertible 
into  an  undesirable  decomposition  of  protein;  still  the  proportion 
of  carbohydrates  must  be  reduced.  The  diet  should  at  first  consist 
of  watery  soups  with  the  addition  of  beef-tea,  butter,  artificial 
albumins,  maggi,  and  a  small  quantity  of  dry  rolls  or  zwieback. 
After  these  have  been  shown  to  be  well  borne,  oat  or  wheat  flour, 
dextrinized  infant  foods  or  flours,  zwieback,  toast,  hominy,  noodles 
and  rice  should  be  given  in  small  quantities,  with  the  addition  of 
protein  nutrients  such  as  eggs,  milk,  bouillon,  very  tender  chopped 
meats,  chicken,  squab,  and  fats  in  the  form  of  butter  and  oil.  The 
quantity  of  the  diet  should  then  be  gradually  increased  until  solid 
food  is  allowed,  the  major  part  consisting  of  proteins  and  fats,  the 
use  of  carbohydrates  being  restricted.  By  following  out  a  diet  of 
this  kind  it  will  usually  be  possible  to  rapidly  reduce  the  fermen- 
tation processes.  Potatoes  should  be  forbidden  for  a  long  time,  as 
they  are  poorly  dextrinated  in  the  intestines  of  such  patients,  and 
in  consequence  the  starch  they  contain  undergoes  fermentation. 
Care  must  likewise  be  exercised,  in  respect  to  milk  when  fermen- 
tation is  present.  Milk-sugar  ferments  very  easily;  it  is  therefore 
advisable  to  add  salicylic  acid  when  milk  is  given. 

When  the  stomach  is  the  primary  cause  of  the  intestinal  disorder, 
it  naturally  must  first  have  proper  treatment. 

LAXATIVE  DIET. 

A  laxative  diet  is  one  which  increases  the  peristalsis  of  the  intes- 
tine, chiefly  by  stimulating  its  muscular  coat.  This  effect  is  brought 
about  by  the  mere  bulk  of  the  food  or  by  its  chemical  properties. 
In  all  conditions  of  chronic  constipation  it  is  necessary  to  examine 
the  feces  most  carefully  in  order  to  be  able  to  outline  a  correct 
dietetic  course.  The  causes  of  constipation  are  so  various  that 
an  exact  analysis  of  the  feces  after  a  test  diet  is  essential  to  a  correct 
understanding  of  the  case.  The  diet  will  have  to  be  different  in 
cases  of  pure  atonic  constipation  from  that  which  is  appropriate  in 
spastic  constipation.  Again,  it  will  differ  when  the  constipation  is 
due  merely  to  weakness  of  the  abdominal  muscles  or  of  the  rectum. 

A  laxative  diet  is  the  exact  reverse  of  a  constipating  or  non- 
irritating  diet.  In  its  use  both  mechanical  and  chemical  stimuli 
are  employed;  the  food  is  coarse  and  plentiful,  and  deliberately 
calculated  to  increase  the  processes  of  decomposition  and  fermen- 
tation. 


LAXATIVE  DIET  183 

The  most  powerful  dietetic  stimuli  are  necessary  in  cases  of 
atonic  constipation  in  which  the  bowel  is  relaxed  and  its  peristaltic 
motility  lost.  Stimulation  of  a  decidedly  weaker  order,  chiefly 
of  a  chemical  nature,  is  employed  in  those  varieties  of  constipation 
which  are  described  as  spastic,  in  which  the  intestine  is  frequently 
overstimulated.  Chemical  stimulation  is  also  useful  in  those  forms 
of  nervous  constipation  which  are  associated  with  intestinal  catarrh 
and  abnormal  secretion  of  mucus. 

By  making  the  diet  large  and  bulky  the  mechanical  effects  are 
obtained.  By  this  means  it  is  possible  to  increase  the  quantity  of 
the  fecal  excrement,  which  is  usually  very  small  in  chronic  con- 
stipation. This  object  is  attained  by  the  giving  of  a  diet  rich  in 
insoluble  residue,  usually  an  increased  amount  of  carbohydrates, 
and  more  particularly  of  foods  rich  in  cellulose.  Quite  erroneous 
views  were  formerly  entertained,  and  even  survive  at  present, 
with  regard  to  the  behavior  of  cellulose  in  the  human  intestinal 
tract.  It  has  always  been  assumed  that  the  human  organism  does 
not  possess  a  digestive  ferment  for  cellulose,  and  that  the  latter 
is  not  subject  to  changes  by  the  digestive  juices  in  the  lower  sections 
of  the  intestine.  It  has  also  been  supposed  that,  particularly  in 
the  large  intestine,  cellulose  undergoes  a  sort  of  fermentation,  due 
to  the  influence  of  bacterial  activity,  being  converted  thereby  into 
marsh  gas,  hydrogen,  acetic  and  butyric  acids.  Lohrisch,  however, 
within  the  last  few  years  has  demonstrated,  as  the  result  of  numerous 
experiments  on  assimilation  and  respiration,  that  cellulose  in  the 
small  intestine  behaves  in  exactly  the  same  manner  as  the  ordinary 
carbohydrates.  Just  like  starch,  it  is  converted  into  sugar  and 
absorbed.  This  necessitates  the  existence  of  a  cellulose  ferment 
— a  cytase.  The  transformation  of  cellulose  into  sugar  proceeds 
much  more  slowly  than  that  of  starch,  for  the  reason  that  cellu- 
lose by  its  very  nature  is  a  hard,  brittle  material,  and  because  in 
plants  it  is  present,  not  in  the  pure  state,  but  mixed  with  and  enveloped 
in  the  so-called  encrusting  substances  (lignin,  cutin).  This  makes 
it  very  difficult  for  the  digestive  juices,  in  particular  the  cytase, 
to  dissolve  the  cellulose.  The  digestion  of  cellulose  is  more  readily 
accomplished  if  the  plants  from  which  it  is  derived  are  quite  young, 
because  then  they  contain  less  encrusting  substances  and  are  more 
easily  subdivided.     (See  page  61.) 

According  to  Lohrisch,  cellulose  is  digested  when  introduced  with 
a  test  diet  in  the  following  proportions:  Average,  58  per  cent.; 
tender  cauliflower,  79  per  cent.;  mashed  spinach,  90  per  cent.; 
bread-cellulose,  85  per  cent.;  and  the  entire  quantity  of  tender 
white  cabbage  may  be  digested  under  certain  circumstances.  It 
may  therefore  be  considered  as  a  settled  fact  that  in  man  nearly 
all  of  the  cellulose  is  regularly  digested,  only  a  small  quantity  being 
expelled  with  the  feces.  A  very  small  fraction  of  undigested  cel- 
lulose may  have  to  undergo  fermentation  in  the  large  intestine. 


184  DIET  IN  INTESTINAL  DISEASES 

Cellulose,  naturally,  will  never  attain  much  importance  as  a  food, 
the  quantity  contained  in  plants  being  so  small. 

It  follows  from  what  has  been  said  that  if  it  is  intended  by 
means  of  a  diet  rich  in  cellulose  to  exert  a  laxative  effect  upon 
the  intestine,  the  food  must  be  as  coarse  as  possible,  comminuted 
only  slightly,  and  not  too  tender  or  too  young.  Otherwise  the 
intended  effect  of  the  feeding  will  be  a  disappointment  because  of 
the  readiness  with  which  the  small  intestine  digests  the  cellulose. 
This  is,  in  fact,  what  frequently  happens  in  cases  of  chronic  atonic 
constipation.  It  is  true  that  in  a  large  number  of  cases  of  chronic 
constipation  a  good  effect  is  obtained  by  a  diet  rich  in  indigestible 
residue,  but  in  many  of  these  cases  the  ingestion  of  large  quantities 
of  cellulose  is  without  any  effect,  and  it  has  been  found  that  these 
patients  digest  cellulose  a  great  deal  better  than  people  with  normal 
intestines.  Lohrisch  was  able  to  demonstrate  that  persons  with 
habitual  constipation,  fed  in  the  same  manner  as  normal  persons, 
would  digest  about  80  per  cent,  of  the  cellulose  introduced  into 
the  intestine,  in  contradistinction  to  the  normal  standard  of  only 
58  per  cent.  This  peculiar  fact  explains  the  negative  effect  of  cel- 
lulose in  many  cases  of  chronic  atonic  constipation.  Such  individ- 
uals are  capable  indeed  of  digesting  everything,  even  the  coarsest 
gritty  foods  (nuts,  almonds),  without  leaving  sufficient  residue  to 
be  of  any  importance  for  stimulating  peristalsis. 

However,  in  every  case  of  chronic  atonic  constipation  the  attempt 
should  be  made  to  provide  a  diet  rich  in  coarse  residue,  for  it  is 
always  a  matter  of  uncertainty  how  the  intestine  will  behave  in 
respect  to  cellulose.  Various  kinds  of  bread  should,  therefore,  be 
used  unsparingly,  e.  g.,  rye  bread,  pumpernickel,  Graham  bread, 
corn  bread,  ginger-cake  and  honey-cake.  Other  special  varieties 
of  bread  are  Rademann's 'cellulose  bread  (3  per  cent,  cellulose) 
and  TVeickers  cellulose  bread  made  of  beechwood  sawdust.  Of 
vegetable  foods,  various  kinds  of  lettuce  and  coarse  vegetables, 
such  as  cabbage,  carrots,  turnips  and  parnsips,  should  be  freely 
utilized. 

Large  quantities  of  raw  and  cooked  fruit  are  always  valuable; 
to  a  certain  extent  they  answer  the  indication  of  making  the  feces 
rich  in  water  and  consequently  softer.  To  get  nearer  to  this  desidera- 
tum Adolf  Schmidt  has  proposed  that  we  give  agar.  This  agar  is 
a  well-known  species  of  Japanese  sea-alga  and  belongs  to  the  so-called 
hemicelluloses,  being  anhydrids  of  various  kinds  of  sugar  (except  dex- 
trose). These  hemicelluloses  are,  chemically,  polysaccharids,  closely 
related  to  cellulose.  Agar  is  the  anhydrid  of  galactose;  it  therefore 
consists  of  galactan,  and  on  being  hydrated  yields  about  70  per  cent, 
of  galactose.  This  hemicellulose,  as  Lohrisch  has  shown,  is  digested 
in  the  human  organism  very  much  like  cellulose,  but  hi  much  larger 
amounts,  and  it  can  be  administered  hi  considerably  larger  quantities. 
A  constipated  person  will  digest  much  more  of  it  than  a  normal 


LAXATIVE  DIET  185 

person.  Still,  if  large  quantities  are  given,  enough  may  remain 
undigested  to  actually  soften  the  stools  to  a  semiliquid  eonsisteney 
(see  page  01).  Large  amounts  of  fat  are  capable  of  acting  in  a 
similar  manner,  rendering  the  feces  soft  and  smooth.  Benedict 
was  the  first  to  draw  our  attention  to  a  similar  effect  from  liquid 
petrolatum  taken  internally  (see  page  G64).  These  substances  may 
therefore  be  employed  advantageously  to  increase  the  effects  of  a 
diet  rich  in  coarse  residue. 

An  immense  variety  of  fruits  must  be  classed  among  the  laxa- 
tives, because  of  their  chemical  constitution.  These  are  of  particular 
value  in  cases  of  spastic  constipation.  They  stimulate  peristalsis 
partly  because  of  their  fruit  acids  and  partly  because  they  contain 
sugar,  which  is  apt  to  increase  the  fermentative  processes  in  the 
intestine.  Fruit  and  its  active  ingredients  may  be  freely  used  as 
jams,  jellies,  fruit  juices,  cider,  etc.  Other  acids  and  acid  foods  are 
recommended,  as  citric  acid,  lactic  acid,  buttermilk,  sour  milk,  whey, 
kefir  (two  days  old),  sour  cream,  yoghurt,  vinegar  and  sauerkraut 
(See  page  G54.) 

The  most  useful  kinds  of  the  various  sugars  are  the  easily  broken- 
up  milk-sugar  and  levulose.  Easily  melted  fats,  as  butter,  oil,  and 
cream,  not  only  have  a  mechanical  effect,  as  has  been  mentioned, 
but  also  act  chemically,  stimulating  peristalsis  by  means  of  the 
great  amount  of  fatty  acids  they  develop.  Some  beverages  have  a 
certain  chemical  action,  as  acidulous  beers  (Weissbier)  and  beverages 
containing  carbon  dioxid. 

All  these  articles  of  diet  frequently  act  particularly  well  when 
taken  on  the  fasting  stomach.  Their  temperature  is  also  of  impor- 
tance. When  taken  cold,  the  stimulation  of  peristaltic  motion  is 
often  much  enhanced.  This  susceptibility  of  the  intestine  to  cold 
goes  far  to  explain  the  effect  of  a  very  cold  glass  of  water  taken  in 
the  morning  immediately  after  rising. 

No  specific  directions,  as  a  rule,  need  be  given  concerning  the 
consumption  of  meat  in  cases  of  constipation.  Meat  may  be  taken 
freely  in  spastic  constipation,  though  some  authors  recommend  a 
restriction  or  even  a  prohibition  of  it,  as  it  is  said  that  it  occasionally 
induces  constipation. 

The  diet  in  the  different  varieties  of  constipation,  generally 
speaking,  is  to  be  formulated  in  such  a  manner  that  a  mechanical 
and  chemical  stimulation  will  be  produced.  An  active  diet  rich 
in  insoluble  residue  is  particularly  indicated  in  chronic  atonic 
constipation.  In  such  cases  there  need  be  no  misgivings  in  advising 
large  quantities  of  coarse  food  so  long  as  the  stomach  is  in  normal 
condition.  Should  the  stomach  be  deranged,  the  ingestion  of 
cellulose  will  have  to  be  considerably  moderated,  and  attempts 
should  be  made  to  proceed  on  other  lines.  Here,  also,  it  is  impera- 
tive to  treat  every  case  individually.  In  cases  of  spastic  constipa- 
tion the  indications  point  to  a  chemically  acting  dietetic  regimen 


186  DIET  IN  INTESTINAL  DISEASES 

exclusively;  all  kinds  of  mechanically  irritating  foods  are  to  be 
absolutely  forbidden.  In  many  cases  it  may  be  necessary  occa- 
sionally to  administer  vegetables  and  boiled  fruit  in  puree  form, 
our  only  dependence  being  the  mildly  laxative  chemical  action  of 
appropriate  foods. 

All  the  articles  enumerated  previously  as  producing  a  constipating 
effect  must  be  absolutely  avoided  (claret,  tea,  cocoa,  acorn-cocoa, 
whortleberries). 


CHAPTER  VIII. 
ARTIFICIAL  FOOD  PREPARATIONS. 

In  cases  where  the  general  nutrition  is  low  and  only  small  quan- 
tities of  food  can  be  ingested,  it  has  been  found  necessary  to  supple- 
ment the  "natural"  diet  by  the  use  of  specially  prepared  nourishing 
agents.  We  have  a  large  number  of  such  preparations  at  our  dis- 
posal. 

To  take  the  place  of  proteolysis  in  the  stomach,  which  is  so 
frequently  deficient  in  chronic  gastro -intestinal  diseases,  a  number 
of  nutritious  preparations  are  manufactured  in  which  the  protein 
is  predigested  into  peptones  and  albumoses.  Preparations  of  this 
class  are  not  necessary  when  the  patient  is  able  to  digest  sufficient 
food  for  his  requirements;  but  they  are  indicated  in  cases  where 
the  general  nutrition  is  low.  Many  of  them  are,  however,  imprac- 
ticable, owing  to  their  disagreeable  taste;  and  the  cost  of  those 
that  can  be  used  is  generally  so  high  as  to  curtail  their  usefulness 
among  patients  in  moderate  circumstances. 

The  protein  preparations  are  made  by  artificial  digestion  of 
protein  by  means  of  animal  and  vegetable  ferments  with  the  aid 
of  organic  and  inorganic  acids,  salts,  bases,  vapors,  and  gases,  in  a 
vacuum  or  under  high  pressure.  The  principal  preparations  of  this 
class  include  the  following: 

Preparations  of  Animal  Protein.- — Somatose  is  a  yellowish  powder, 
nearly  tasteless  and  odorless,  and  readily  soluble  in  water.  It  con- 
tains over  90  per  cent,  of  albumoses,  is  easily  assimilated,  and  stim- 
ulates appetite  and  gastric  secretion.  It  has  been  employed  with 
benefit  in  chronic  gastritis,  in  gastric  crises  after  surgical  operations 
on  the  stomach  and  intestine,  in  carcinoma,  in  nervous  dyspepsia 
and  anorexia,  and  in  acute  gastroenteritis.  Somatose  is,  however, 
not  well  borne  in  hyperacidity.  The  dose  is  three  or  four  dessert- 
spoonfuls a  day.  Its  proper  use  is  as  an  adjuvant  in  connection 
with  the  prescribed  diet,  to  supplement  the  nutritive  value  of  the 
latter.  Somatose  has  the  action  of  a  tonic  rather  than  that  of  a 
food.  Iron  somatose  has  been  furnished  by  pharmaceutical  houses. 
In  iron  somatose  the  iron  is  organically  combined;  this  preparation 
is  indicated  in  cases  of  chlorosis  complicated  with  gastrointes- 
tinal disturbance;  the  adult  dose  is  three  or  four  dessertspoonfuls 
dailv. 


188  ARTIFICIAL  FOOD  PREPARATIONS 

Carringen,  or  somatine,  occupies  a  place  between  somatose  and 
meat  extract  as  regards  composition;  its  effect  is  stimulating.  Its 
cost  renders  it  impracticable  as  a  food. 

Troyon  is  prepared  from  animal  and  vegetable  protein,  and  is 
useful  as  a  cheap  meat  powder.  It  contains  90  to  99  per  cent,  of 
protein,  and  is  insoluble  in  water.  It  is  administered  in  bouillon, 
milk,  cocoa,  and  soup.  The  quantity  to  be  given  should  be  boiled 
with  a  small  portion  of  the  nutrient  vehicle  in  which  it  is  to  be 
taken,  and  then  mixed  with  the  entire  amount. 

Salvatose,  a  French  preparation,  is  a  pure  protein  product.  It 
is  seldom  used. 

Fersan  contains  80  to  90  per  cent,  of  organically  combined 
soluble  protein.  Fresh  ox-blood  mixed  with  twice  its  volume  of 
a  1-per-cent.  solution  of  sodium  chlorid  is  centrifugalized,  com- 
pletely separating  the  serum  containing  the  metabolic  products; 
the  corpuscles  are  then  dried  in  vacuo,  and  powdered.  Fersan 
is  a  dark  brown,  odorless  powder  with  a  slightly  acid  taste,  soluble 
in  water,  and  containing  a  large  percentage  of  iron  and  phosphorus. 
The  phosphorus  is  present  in  complete  organic  combination,  and 
the  iron  almost  entirely  so.  The  preparation  is  an  iron  albuminate 
that  calls  for  no  digestive  activity  on  the  part  of  the  stomach. 
It  is  not  coagulated  in  the  stomach,  and  is  completely  absorbed  by 
the  intestine.    The  dose  is  three  to  six  teaspoonfuls  a  day,  in  milk. 

Peptones. — Peptone  preparations  are  now  but  seldom  employed. 
Their  nutritive  value  is  due  chiefly  to  the  albumoses  they  contain. 
Laboratory  experimentation  and  clinical  experience  have  shown 
that,  in  order  to  obtain  sufficient  nourishment  from  the  peptone 
preparations,  unduly  large  quantities  must  be  ingested.  Peptones 
have,  as  a  rule,  a  disagreeable  taste.  In  large  doses  they  tend  to 
produce  diarrhea.  Among  the  most  satisfactory  preparations  of 
this  class  the  following  may  be  briefly  mentioned:  The  meat  solu- 
tion of  Leube-Rosenthal  contains  9  to  12  per  cent,  of  soluble  pro- 
tein and  1.8  to  6.6  per  cent,  of  peptone.  Peptone  chocolate  con- 
tains only  6  per  cent,  more  protein  than  the  ordinary  cocoa. 
Denayer's  fluid  meat  peptone  is  merely  a  strong  beef  tea,  pleasant 
to  the  taste,  used  principally  as  a  stimulant,  containing  1.5  per 
cent,  peptone  and  10.5  per  cent,  albumoses.  Koch's  peptone  con- 
tains 18.8  per  cent,  peptone,  16  per  cent,  propeptone,  and  1.4  per 
cent,  insoluble  protein.  Cibil's  peptone  contains  28.1  per  cent, 
peptone  and  5.8  per  cent,  albumoses. 

Among  the  artificial  food  preparations  made  in  the  United 
States  we  have  the  following,  with  their  nutritive  values,  and  a 
comparison  with  cow's  milk,  as  determined  by  the  Council  of 
Pharmacy  and  Chemistry  of  the  American  Medical  Association: 


( !ai  bo- 

hydrates. 

Protein, 

5.34 

4.28 

5  7s 

0.21 

6.05 

1  51 ) 

13.47 

3.84 

10 .  57 

4.93 

11.53 

4.53 

4.37 

2.38 

4.55 

2.59 

15.43 

0.64 

15.57 

0.43 

12.89 

1.86 

13.19 

1.16 

11.92 

6.38 

10.05 

6.33 

11.46 

2.54 

2.36 

3.40 

2.22 

3.28 

0.55 

1.81 

4.80 

3.50 

PEPTONE  PREPARATIONS  189 


Name  <>i  substai Name  of  manufacturer 

J.  Carpanutrine  John  Wyeth  &  Bro. 

2.  Carpanutrine  John  Wyeth  &  Bro. 

3.  Liquidpeptones  Eli  Lilly  A  Co. 
I.  Liquidpeptones  with  Creosote  Eli  Lilly  &  Co. 

5.  Liquidpeptonoids  Arlington  Chemical  Co. 

6.  Liquidpeptonoids  Arlington  Chemical  Co. 

7.  Predigested  Beef  II.  K.  Mulford  Co. 

8.  Predigested  Beef  II.  K.  Mulford  Co. 

9.  Nutrient  Wine  of  Beef  Peptone  Armour  &  Co. 

10.  Nutrient  Wine  of  Beef  Peptone  Armour  &  Co. 

11.  Nutritive  Liquid  Peptone  Parke,  Davis  &  Co. 

12.  Nutritive  Liquid  Peptone  Parke,  Davis  &  Co. 

13.  Panopeptone  Fairchild  Bros.  &  Foster 

14.  Panopeptone  Fairchild  Bros  &  Foster 

15.  Peptonic  Elixir  Win.  Merrell  Chem.  Co. 

16.  Tonic  Beef  S.  &  D.  Sharp  &  Dohme 

17.  Tonic  Beef  S.  &  D.  Sharp  &  Dohme 

18.  Liquid  Peptone  Stevenson  &  Jester  Co. 

19.  Cow's  Milk  (3.8  per  cent,  fat) 

There  are  no  fatty  substances  in  these  products;  their  food  value 
from  this  point  of  view  is  therefore  a  negative  quantity.  They 
all  contain  alcohol;  the  proportion  ranges  from  14  to  23  per  cent. 
The  printed  matter  distributed  by  some  manufacturers  leads  the 
physician  to  believe  that  these  preparations  contain  sufficient 
nutritive  material  to  maintain  the  normal  nutrition  of  the  body. 
The  average  quantity  that  can  be  taken  daily  ranges  from  60  to 
150  Cc.  (2  to  5  ounces),  the  total  available  calories  of  which, 
based  on  the  protein  and  carbohydrate  bodies,  varies  from  9.8  to 
110.5.  Adding  to  these  figures  the  amount  of  energy  represented 
by  the  alcohol,  in  each  case,  the  total  available  calories  will  vary 
from  55  to  229.5.  The  number  of  calories  required  per  diem  by  a 
man  doing  very  moderate  work  approximates  3000.  In  sickness 
the  amount  required  is  not  so  great,  but  on  the  average  should 
not  fall  much  below  1500  calories  for  the  twenty-four  hours.  This 
consideration  alone  shows  the  fallacy  of  the  representation  that 
any  of  the  artificially  prepared  foods  above  mentioned  will  enable 
the  patient  to  dispense  with  other  nourishment. 

The  report  of  the  Council  of  Pharmacy  and  Chemistry  goes  on 
to  say: 

"In  order  to  get  a  fair  conception  of  the  actual  food  value  of 
these  various  preparations,  it  is  desirable  to  make  some  comparison 
which  can  be  readily  comprehended  by  every  physician.  The 
amount  of  good  milk  necessary  each  twenty-four  hours  to  sustain 
the  vitality  of  a  patient  during  a  serious  illness  is  not  less  than  64 
ounces,  or  approximately  2000  Cc.  [2  quarts].  The  food  value  in 
calories  represented  by  this  amount  of  good  milk  may  be  placed  at 
1430.  This  includes  not  only  the  protein  and  carbohydrate  mat- 
ter, but  the  fat  as  well.  By  comparing  this  available  potential 
energy  with  the  total  energy  available  in  the  predigested  foods  under 
consideration,  it  can  be  readily  seen  that  if  a  physician  depends  on 
the  representations  made  by  some  of  the  manufacturers,  and  feeds 


190  ARTIFICIAL  FOOD  PREPARATIONS 

his  patient  accordingly,  he  is  resorting  to  a  starvation  diet.  The 
largest  number  of  available  calories,  including  alcohol,  present  in 
any  of  the  recommended  daily  doses  is  less  than  one-fifth  of  the 
number  of  calories  represented  by  2000  Cc.  of  milk;  and  the  calories 
represented  by  the  daily  dose  of  the  preparation  poorest  in  food 
products  is  only  one-twenty-fifth  of  the  amount  present  in  2000  Cc. 
of  milk.    These  figures  tell  their  own  story. 

"Making  2000  Cc.  of  milk  the  basis  of  calculation,  and  estimating 
the  amount  of  the  various  preparations  required  to  yield  this  num- 
ber of  calories,  it  is  found  that  the  quantity  to  be  administered 
daily  to  supply  1430  calories,  including  alcohol,  varies  from  716.2 
to  1506.2  cubic  centimeters  (or  approximately  one  to  three  pints). 
In  many  cases  the  amount  of  alcohol  exhibited  by  these  quantities 
would  keep  the  patient  in  an  alcoholic  stupor  continually.  The 
cost  necessary  to  supply  this  energy  varies  from  $1.48  to  $3.39. 
Compare  these  prices  with  the  cost  of  two  quarts  of  milk.  Is 
further  comment  necessary? 

"The  average  number  of  calories  represented  by  500  grams 
of  these  products  as  proteins  and  carbohydrates  is  260.6.  The 
total  average  caloric  value  of  the  same  amount  of  these  foods  is 
802.4. 

"The  number  of  calorie,s  represented  by  good  brandies  or  whis- 
kies, containing  45  per  cent,  of  alcohol,  is  1575.  In  other  words,  the 
average  caloric  value  of  these  preparations  is  approximately  one- 
half  that  contained  in  either  good  brandy  or  whisky.  From  this 
it  must  not  be  concluded,  however,  that  equal  quantities  of  brandy 
or  whisky  are  twice  as  valuable  as  the  medicinal  foods,  because 
the  medicinal  foods  contain  some  material  which  can  be  utilized 
in  building  tissue,  which  is  not  the  case  with  either  whisky  or 
brandy. 

"From  the  above  it  can  readily  be  seen  that  not  only  is  the 
patient  receiving  a  starvation  diet  when  the  physician  resorts  to 
these  preparations,  but  the  unfortunate  sick  are  also  compelled 
to  pay  exorbitant  prices  for  the  amount  of  actual  nutritive  matter 
received. 

"It  is  urged  in  justification  of  the  use  of  preparations  of  this 
class  that  they  contain  constituents  not  found  in  our  ordinary 
foods  and  in  a  more  perfectly  assimilable  condition.  As  pointed 
out  above,  these  so-called  predigested  foods  contain  no  fats;  the 
carbohydrates  in  them  are  the  ordinary  sugars  present  in  our 
common  foods,  while  the  proteins  belong  to  the  peptone  or  albumose 
class.  It  is  for  these  latter  that  the  greatest  claims  are  made,  but 
even  here  no  value  can  be  pointed  out  not  found  in  whey,  peptonized 
full  milk,  or  peptonized  skimmed  milk. 

"There  is  likewise  another  point  of  considerable  importance  to 
consider  in  this  connection.  The  terms  peptone  and  albumose 
include  bodies  of  very  uncertain  composition,  and  their  suitable- 


FROM  VEGETABLE  AND  MILK  PROTEINS  191 

ness  as  food  substances  depends  largely  on  how  they  are  prepared. 
Animal  experiments  have  shown  that  nitrogen  equilibrium  may  be 
maintained,  for  a  time  at  least,  by  the  use  of  enzymic  hydrolytic 
products  of  the  proteins,  even  where  the  hydrolysis  has  been  car- 
ried far  beyond  the  so-called  peptone  stage,  but  it  appears  to  be 
likewise  true  that  the  mixtures  secured  by  acid  or  high  tempera- 
ture steam  hydrolysis  have  no  such  value.  Some  of  these,  indeed, 
may  exhibit  a  toxic  behavior.  This  is  true  in  particular  of  some 
of  the  commercial  varieties  of  peptone,  and  until  more  is  known 
of  the  source  of  the  bodies  of  protein  character  employed  in  the 
make-up  of  these  '  predigested'  mixtures  it  is  unwise  to  assume 
anything  concerning  the  food  value  of  the  nitrogen  compounds 
found  in  them  by  analysis  or  even  to  dignify  them  by  the  name  of 
foods." 

Edsall,  commenting  upon  this  report,  argues  against  the  use  of 
proprietary  foods.  The  development  of  a  moderate  degree  of 
skill  and  resource  in  the  use  of  simple  and  comparatively  cheap 
home  preparations  will  obviate  any  tendency  to  use  the  proprie- 
tary article.  This  writer  cites  instances  where  patients  virtually 
starved  to  death  through  the  mistaken  belief  of  the  physician  that 
they  were  receiving  sufficient  nutrition  from  the  much-vaunted  pro- 
prietary food.  A  very  important  disadvantage  of  these  foods  is 
their  alcohol  content.  This  evil  is  dwelt  upon  in  the  Council's 
report. 

Preparations  from  Vegetable  Protein. — Among  these  we  have: 

Roborat,  obtained  from  grain  seeds,  wheat,  corn,  and  rice.  It 
is  a  fine,  yellowish-white,  odorless,  tasteless  powder,  only  slightly 
soluble  in  cold  water.  It  contains  83  per  cent,  of  vegetable  pro- 
tein. This  preparation  is  fairly  well  assimilated.  It  has  been 
found  of  value  in  the  treatment  of  gastric  ulcer,  atony,  dilatation, 
erosions,  enteritis,  and  chlorosis  associated  with  gastro-intestinal 
disease.  It  may  also  be  administered  as  a  nutritive  enema. 
Roborat  may  be  given  in  milk  or  water. 

Aleuronat  flour  is  prepared  from  gluten.  It  contains  82  to  86 
per  cent,  of  vegetable  protein;  is  almost  tasteless,  and  is  insoluble 
in  water. 

Mutase  is  a  vegetable  casein  prepared  from  leguminous  seeds. 
It  is  not  expensive. 

Food  Preparations  from  Milk  Protein.— These  preparations  contain 
the  casein  of  milk  and  are  for  the  most  part  useful  foods. 

Nutrose  is  casein  sodium,  a  white,  odorless,  tasteless  powder 
containing  85  to  90  per  cent,  of  protein.  It  is  soluble  in  warm 
water.  Nutrose  is  almost  completely  absorbed  by  the  small  intes- 
tine. The  casein  constituent  does  not  give  rise  to  decomposition 
in  the  intestine.  Nutrose  has  been  employed  in  all  kinds  of  gastro- 
intestinal diseases  in  which  a  mild,  non-irritating  and  nutritive 
food  is  indicated. 


192  ARTIFICIAL  FOOD  PREPARATIONS 

Eucasin,  casein  ammonium,  is  an  odorless,  tasteless  powder  con- 
taining 85  to  90  per  cent,  of  protein;  it  is  soluble  in  water. 

Sanatogen  contains  95  per  cent,  casein  and  5  per  cent,  glycero- 
phosphate of  sodium;  the  insoluble  casein  has  been  transformed  by 
the  glycerophosphate  into  a  compound  soluble  in  water.  Sanato- 
gen is  well  borne  by  patients  suffering  from  gastric  ulcer,  gastritis, 
or  acute  intestinal  catarrh.  The  dose  for  adults  is  one  to  three 
tablespoonfuls  three  times  a  day.  Cow's  milk  contains  all  the 
ingredients  claimed  for  sanatogen.  Ten  cents'  worth  of  cow's  milk 
will  give  the  same  number  of  calories  as  three  dollars'  worth  of  sana- 
togen, and  the  latter  has  no  more  favorable  effect  than  cow's  milk. 

Plasmon  consists  of  protein  obtained  by  a  mechanical  process 
from  skimmed  milk.  It  is  a  milk-white,  tasteless  powder  con- 
taming  74.5  per  cent,  of  protein.  Plasmon  is  easily  soluble  in  hot 
water,  and  is  almost  completely  absorbed  in  the  intestine.  Con- 
centrated solutions  curdle  on  cooling.  Plasmon  is  useful  in  the 
treatment  of  gastric  ulcer  and  intestinal  catarrhs.  It  may  be 
taken  in  connection  with  a  variety  of  foods,  as  plasmon-chocolate, 
plasmon-cocoa,  plasmon-beef.  It  is  a  good  food,  as  well  as  the 
cheapest  of  the  casein  preparations. 

Milk  somatose  is  prepared  from  the  casein  of  milk,  and  contains 
5  per  cent,  of  tannin  hi  chemical  combination.  It  is  a  yellowish- 
brown,  odorless,  almost  tasteless  powder,  soluble  in  hot  water. 
Milk  somatose  is  non-irritating,  and  may  be  employed  with  advan- 
tage in  the  treatment  of  chronic  intestinal  catarrh;  it  is  likewise 
useful  in  the  treatment  of  dysentery  and  intestinal  tuberculosis. 
The  dose  is  four  teaspoonfuls  daily.     (See  page  277.) 

Globon  is  a  derivative  of  casein  obtained  by  breaking  up  nucleo- 
protein  by  means  of  alkalis. 

Galactogen  is  prepared  from  milk;  is  completely  soluble  and  easily 
digested.  It  contains  70  per  cent,  of  protein,  and  is  agreeable  to 
the  taste  and  pleasant  to  take  in  the  form  of  galactogen-chocolate 
(20  to  22  per  cent,  soluble  protein)  or  galactogen-cocoa  (30  to  32 
per  cent,  soluble  protein). 

Mam  mala  is  cow's  milk  modified  by  removing  a  part  of  the 
cream,  adding  milk-sugar,  and  drying  in  vacuo. 

Nutritive  Substances  from  Egg  Protein. — Xidritive-Heyden  is  pre- 
pared from  the  whites  of  fresh  eggs,  and  contains  90  per  cent, 
of  protein.  It  is  soluble  only  in  hot  water.  The  dose  is  three  to 
four  dessertspoonfuls,  in  cocoa,  soup,  or  milk.  It  may  be  given 
also  as  an  enema. 

Protogen  is  a  formaldehyde  protein  prepared  by  the  action  of 
formalin  on  egg  protein.     It  is  not  much  used. 

Preparations  from  Carbohydrates. — These  preparations  are  better 
adapted  than  protein  compounds  to  increase  the  nutritive  value 
of  certain  foods,  especially  soups,  and  to  serve  as  substitutes  for 
ordinarv  diet. 


MIXED  NUTRITIVE  PREPARATIONS  193 

Finely  Diddcd  Flours. — Ilartenstein's  Iegiiinins  arc  furnished  in 
four  mixtures: 

I  ...  27  per  cent,  protein;  62  per  cent,  carbohydrates. 

II  ...  21         "  "        68 

III  .      .      .  18         "  "       69 

IV  ...  15         "  "       72 

Knorr's  Flours  (oat,  barley,  rice,  bean,  lentil,  pea)  contain 
7  to  25.5  per  cent,  protein,  57  to  79  per  cent,  carbohydrates. 

The  meals  belonging  to  this  class  are  rolled  oats  and  oatmeal — 
12.07  per  cent,  protein,  63.8  per  cent,  carbohydrates. 

The  utility  of  these  preparations  is  great,  compared  with  that 
of  corresponding  products  in  common  use. 

Dextrinated  Flours. — In  these  flours  the  carbohydrates  are  dex- 
tr mated.  To  this  group  belong  the  extensive  series  of  infant's 
flours — Carnrick's  lactated  milk,  malted  milk,  Ridge's,  Wagner's, 
Mellin's,  Nestle's,  Eskay's,  Allenburys',  and  Imperial  Granum. 
Owing  to  the  fact  that  it  contains  dextrinated  starch,  malt  extract 
also  belongs  to  this  group.  Malt  extract  is  a  well-known  product 
of  germinating  barley;  it  contains,  condensed  to  a  syrupy  con- 
sistence, 50  to  55  per  cent,  of  sugar,  of  which  10  to  15  per  cent,  is 
dextrinated  soluble  starch.  Loeflund's  malt  soup  is  a  good  food. 
It  contains  57  per  cent,  of  maltose  and  12.4  per  cent,  of  dextrin. 
Maltose  buttermilk,  containing  dextri-maltose  and  wheat  flour,  is 
a  serviceable  article  of  diet  in  cases  of  disturbed  nutritional  balance 
with  excess  of  fat.  The  malt  extracts  of  Keppler,  Trommer,  maltine, 
and  malt  beers  have  no  particular  value  as  food  agents. 

Mixed  Nutritive  Preparations.— The  preparations  above  men- 
tioned contain  not  only  carbohydrates,  but  also  more  or  less  protein. 
Recently  mixtures  of  carbohydrates  and  proteins,  the  latter  partially 
treated  with  ferments,  have  been  offered.  Among  such  preparations 
we  have: 

Hygiama,  consisting  of  condensed  milk,  especially  prepared 
cereals,  and  fat-free  cocoa.  It  contains  22.8  per  cent,  protein, 
61.6  to  63.32  per  cent,  carbohydrates.  Two  dessertspoonfuls  with 
one-quarter  liter  (8  ounces)  of  milk,  three  or  four  times  a  day, 
constitute  the  dose.  Hygiama  tablets  may  be  eaten  without  any 
further  preparation. 

Odda  is  a  mixture  of  yolk  of  egg,  cocoa  fat,  whey,  dextrinated 
flour  and  other  carbohydrates.  It  contains  16.56  per  cent,  protein 
and  18.14  per  cent,  carbohydrates. 

Protein-milk-salt-cocoa,  a  new  compound  originated  by  Simon, 
of  Carlsbad,  belongs  to  this  division.  It  is  a  cocoa  containing 
only  15  per  cent,  of  fat,  combined  with  37.23  per  cent,  of  protein 
predigested  with  ferments,  and  7.61  per  cent,  of  nutritive  milk 
salts.  Up  to  74  per  cent,  of  the  protein  of  this  cocoa  is  digestible, 
and  the  cocoa  itself  contains  more  digestible  protein  than  an  equal 
weight  of  raw  beef.  The  taste  is  very  pleasant.  This  cocoa  is 
13 


194  ARTIFICIAL  FOOD  PREPARATIONS 

particularly  useful  in  cases  of  chronic  gastro-intestinal  disease, 
especially  as  its  cost  is  comparatively  low. 

Racahout  is  a  compound  of  chocolate,  sugar,  and  Arabian  meal, 
very  nutritious  and  agreeable.  It  is  useful  in  all  gastro-intestinal 
diseases.  Two  to  four  teaspoonfuls  are  added  to  milk,  which  is 
then  allowed  to  boil  for  seven  or  eight  minutes. 

Acorn-cocoa  consists  of  pure  cocoa  deprived  of  a  large  part  of 
its  fatty  matter  and  combined  with  a  soluble  extract  of  roasted 
acorns  free  from  cellulose.  A  small  amount  of  roasted  flour  and 
sugar  is  added.  On  account  of  its  astringent  properties  it  is  valuable 
in  gastric  catarrh  and  all  forms  of  enteritis. 

Preparations  Containing  Pat. — Russell's  Emulsion  contains  beef 
suet,  cocoanut  oil,  peanut  oil,  and  cottonseed  oil,  to  the  extent  of 
42  per  cent,  of  its  volume. 

Nutrole  contains  40  per  cent,  of  mixed  animal  and  vegetable  oils, 
emulsified  with  fresh  eggs. 

Sevetol  is  a  natural  emulsion  of  mixed  fats  with  proteins  and 
carbohydrates.  The  fats  are  butter,  beef  fat,  olive  oil,  lard,  and 
peanut  oil;  these  make  up  30  per  cent,  of  the  whole  mixture. 

Cod-liver  oil  contains  a  considerable  proportion  of  fatty  acids 
with  biliary  elements.  It  is  rich  in  vitamin,  the  crude  oil,  more  so 
than  the  refined.  It  is  converted  by  means  of  the  bile  into  a  very 
fine  emulsion,  and  is  most  thoroughly  absorbed.  Its  taste  is  exceed- 
ingly repugnant.  Cod-liver  oil  in  elastic  gelatin  capsules  can  some- 
times be  taken  by  those  who  cannot  take  the  oil  unmasked. 

Oil  of  sesame  is  more  agreeable  to  the  taste  than  cod-liver  oil, 
and  cheaper. 

Lipanin  is  a  cod-liver  oil  substitute,  consisting  of  a  mixture  of 
94  parts  fine  olive  oil  and  6  parts  oleic  acid.  It  has  a  pleasant  taste 
and  causes  no  subjective  discomforts. 

Mering's  "Kraft"  Chocolate  contains  72.44  per  cent,  fat  to  which 
oleic  acid  has  been  added.    It  is  very  easily  digested. 

Milk  Preparations. — Vegetable  Milk  is  made  of  nuts  and  milk  of 
almonds  (10  per  cent,  protein,  25  per  cent,  fat,  38.5  per  cent,  sugar). 

Pfund's  Cream  Protein  Mixture  is  a  mixture  of  various  kinds 
of  proteins  with  milk-sugar,  cream,  and  water. 

Gartner's  Fat  Milk  and  Voltmer's  Mother's  Milk  are  fat  milks 
digested  with  pancreatic  juice;  they  are  very  similar  to  human 
milk. 

Kefir  and  koumiss  are  preparations  of  milk  which  have  been  sub- 
jected to  fermentation  (see  page  164). 

Stimulating  Preparations. — Liebig's  Meat  Extract  contains  the 
extractives  of  meat,  the  meat  bases  xanthin  and  creatin,  and 
inorganic  salts. 

Toril  Meat  Extract,  Beef  Tea,  and  Valentine's  Meat  Juice  are 
poorer  in  extractives  than  Liebig's  meat  extract. 


RELATIVE  VALUES  OF  MEAT  EXTRACTS  195 

Brand's  Essence  of  Beef,  Meat  Juice,  Fluid  Meat,  and  Bovril, 
much  used  in  England,  contain  smaller  quantities  of  extractive 
than  Liebig's  extract  of  meat. 

Karno  is  less  nutritious  than  Liebig's  extract  of  meat. 

Maggi's  Condiment  is  cheap  and  good.  Maggi's  Bouillon  is  also 
to  be  recommended  as  a  stimulating  preparation. 

Composition  and  Relative  Values  of  Meat  Extracts. — The  Bureau 
of  Chemistry  of  the  Department  of  Agriculture,  in  its  Bulletin 
No.  114,  has  given  valuable  data  regarding  the  commercial  meat 
products.  The  preparations  taken  up  are  divided  into  three  general 
classes : 

1.  Solid  and  fluid  meat  extracts. 

2.  Meat  juices. 

3.  Miscellaneous  preparations. 

Meat  extracts  are  not  to  be  considered  as  foods,  and  should 
therefore  not  be  advertised  as  such — a  conclusion  which  the  govern- 
ment officials  have  arrived  at,  and  which  they  have  stated  as 
follows : 

"It  seems  to  be  the  consensus  of  opinion  among  scientific  inves- 
tigators who  have  studied  this  question  that  the  food  value  of 
these  meat  extracts  is  rather  limited,  and  although  they  are  a 
source  of  energy  to  the  body  they  must  not  be  looked  on  as  repre- 
senting in  any  notable  degree  the  food  value  of  the  beef  or  other 
meat  from  which  they  are  derived.  ^Yhen  prepared  under  the  best 
possible  conditions  a  commercial  meat  extract  is  of  necessity,  in 
order  that  it  may  not  spoil,  deprived  of  the  greater  part  of  coagulable 
proteins,  which  constitute  the  chief  nutritious  elements  of  the 
juice." 

The  physician  should  realize  that  in  prescribing  preparations 
that  have  but  little  food  value  he  may  actually  starve  the  patient. 
According  to  the  high  authority  quoted,  the  claims  of  the  manu- 
facturers in  regard  to  the  food  value  of  "meat  extracts"  and  "meat 
juices"  are  ridiculous.  The  therapeutic  uses  of  these  preparations 
are  therefore  limited.  It  has  been  claimed  that  such  substances 
stimulate  appetite  and  the  nervous  system.  They  may  stimulate 
the  appetite,  but  their  effects  upon  the  nervous  system  are  open 
to  question. 

The  belief  of  many  people  that  bouillon  cubes  are  concentrated 
meat  extracts  and  of  high  nutritive  value,  has  been  shattered  by 
a  recently  issued  bulletin  of  the  Department  of  Agriculture,  which 
says  that,  while  they  are  valuable  stimulants  or  flavoring  agents, 
they  have  little  or  no  real  food  value  and  are  expensive.  The 
ordinary  commercial  bouillon  cubes  consist  of  from  49  to  72  per 
cent,  table  salt.  As  they  range  in  price  from  10  to  20  cents  an  ounce, 
purchasers  of  these  cubes  are  buying  salt  at  a  high  price.  The 
cubes  do  contain  a  small  amount  of  protein  in  addition  to  their 


196  ARTIFICIAL  FOOD  PREPARATIONS 

stimulating  ingredients,  and  the  makers  of  most  of  the  cubes  make 
no  advertised  claim  that  they  are  concentrated  beef  broth  or 
essence.  However,  many  housewives  believe  that  they  are  and 
that  they  possess  high  nutritive  value,  especially  for  invalids. 
This  is  not  the  case.  The  fact  that  each  cube  makes  a  cup  of  broth 
misleads  the  housewife  into  believing  that  she  is  securing  meat 
extract  cheaply  when  really  she  is  buying  it  in  an  expensive  form. 


CHAPTER  IX. 
LAVAGE  OF  THE  STOMACH. 

Lavage,  or  the  washing  out  of  the  stomach,  is  not  practiced 
nearly  so  often  as  it  was  at  one  time.  Our  knowledge  of  the  exact 
course  of  many  diseases  of  the  stomach,  and  of  the  pathologic 
changes  accompanying  them,  has  advanced.  Lavage  was  formerly 
used  in  the  treatment  of  many  conditions  in  which,  with  our  more 
accurate  knowledge,  it  has  now  been  discarded. 

Indications. — Lavage  is  always  indicated  in  stenosis  of  the  pylorus 
with  dilatation — in  fact,  in  any  obstruction  of  the  digestive  tract 
which  produces  a  stasis  of  the  stomach  contents  with  fermentation 
and  putrefaction.  Good  results  are  not  attained  in  the  treatment 
of  simple  atony  by  means  of  lavage,  because  in  this  condition  we 
are  dealing  with  a  retarded  peristalsis  and  not  with  a  direct  obstacle 
to  the  passage  of  food  into  the  duodenum;  the  washing-out  process 
does  not  tend  to  remove  the  cause,  but  involves  the  danger  of 
overdistention  of  the  relaxed  gastric  walls,  which  is  apt  to  be  harmful. 

In  certain  conditions  lavage  is  of  inestimable  value;  it  is  indicated: 

1.  In  those  cases  of  poisoning  in  which  the  tube  can  do  no  dam- 
age. There  is  always  danger  of  perforation  when  the  poison  has 
been  an  escharotic  or  caustic.  In  morphin  poisoning  the  tube 
should  be  used  even  if  the  drug  has  been  taken  hypodermically, 
since  much  of  the  morphin  injected  hypodermically  is  found  in 
the  stomach  within  an  hour  after  the  injection. 

2.  In  cases  of  uncontrollable  vomiting,  as  in  intussusception 
or  intestinal  obstruction.  There  have  been  cases  reported  in  which 
lavage  so  relieved  abdominal  distention  near  the  obstruction  as 
to  result  in  almost  immediate  recovery.  Stercoraceous  vomiting 
always  demands  lavage,  no  matter  what  the  cause  may  be. 

3.  In  cases  of  gastritis  with  the  production  or  presence  of  large 
quantities  of  mucus. 

4.  In  dilatation  with  stenosis  of  the  pylorus.  Here  fermentation 
and  putrefaction  can  be  inhibited  by  lavage.  These  are  the  cases 
concerning  which  Kussmaul  originally  called  our  attention  to  the 
value  of  stomach  washing. 

5.  In  acute  postoperative  dilatation. 

6.  Before  any  operation  on  the  stomach  or  intestine  is  performed. 

7.  In  vomiting  following  any  operation  on  the  stomach  or  intes- 
tine. 

8.  To  obviate  postoperative  vomiting  after  an  anesthetic. 

9.  In  intestinal  paresis  following  operation. 


198  LAVAGE  OF  THE  STOMACH 

10.  Lavage  with  ice-water  in  hemorrhage  caused  by  gastric  ulcer 
(Ewald).  Lavage,  carefully  applied,  in  severe  hemorrhage  from 
gastric  ulcer,  is  the  most  expedient  means  of  treatment  (Kaufmann) . 

11.  In  meteorism  of  typhoid  fever  it  is  frequently  of  great  benefit. 

12.  In  gastric  tetany. 

13.  In  vomiting  in  cases  of  peritonitis. 

14.  In  acute  gastritis  due  to  improper  eating,  and  in  convulsions 
following  overfeeding. 

15.  In  cicatricial  closure  of  the  pylorus,  as  a  palliative  measure 
until  operation  is  performed. 

16.  In  hematemesis  following  stomach  operation,  cautiously. 
The  stomach  may  be  distended  with  fluid  and  blood,  removal  of 
which  will  allow  it  to  contract  and  thus  stop  the  oozing  of  blood 
(Mayo). 

17.  In  diabetes  mellitus  (Sawyer). 

18.  In  selected  cases  of  nephritis  when  urea  is  being  eliminated 
through  the  gastric  mucous  membrane. 

19.  In  eclampsia. 

Contra-indications. — Lavage  as  well  as  the  use  of  the  tube  for 
diagnostic  purposes  is  contra-indicated : 

1.  In  those  cases  of  gastric  disease,  for  the  most  part  of  sudden 
onset,  which  have  not  attained  any  degree  of  chronicity  and  where 
the  diagnosis  is  apparent  from  the  symptoms  and  history  of  the 
case. 

2.  Where  the  retching  and  vomiting  are  apt  to  offset  any  good 
that  may  be  derived  from  the  use  of  the  tube  either  for  diagnostic 
purposes  or  for  lavage. 

3.  In  marked  prostration,  no  matter  what  the  cause. 

4.  In  broken  compensation  in  heart  disease,  angina  pectoris,  or 
advanced  degeneration  of  the  heart  muscle,  and  in  cardiac  neuroses, 
aneurysm  of  the  aorta,  and  marked  cases  of  arteriosclerosis. 

5.  In  hemorrhages  of  recent  occurrence,  as  in  apoplexy,  pul- 
monary, renal,  gastric  and  rectal  hemorrhages. 

6.  In  pulmonary  tuberculosis,  emphysema,  and  severe  bronchitis. 

7.  In  neurasthenia,  hysteria,  and  epilepsy. 

8.  In  advanced  cachexia. 

9.  In  continued  and  remittent  fever. 

10.  In  pregnancy. 

11.  In  gastric  ulcer  when  hematemesis  has  been  recent  or  when 
blood  has  been  found  in  the  stool;  in  carcinoma  of  the  pylorus 
accompanied  by  the  classic  symptoms  of  carcinoma;  in  gastric  or 
intestinal  diseases  accompanied  by  acute  fever;  and  in  cases  in 
which  the  gastric  mucous  membrane  is  easily  irritated  so  that 
bleeding  results  upon  the  passage  of  the  stomach  tube. 

Any  rules  which  may  be  laid  down  in  regard  to  the  use  of  the 
stomach  tube  are  at  best  but  general.  The  good  judgment  of  the 
physician  must  always  be  superadded,  whether  the  question  be  one 


TECH  NIC  OF  LAVAGE  OF  STOMACH 


199 


of  diagnosis  or  treatment,  inasmuch  as  there  may  he  conditions 
present  which  outweigh  all  stated  rules  on  the  subject. 

Technic. — Lavage  consists  in  the  washing-out  of  the  stomach  by 
means  of  a  simply  constructed  apparatus — a  stomach  tube  (Fig. 
1(>,  A)  connected  with  a  glass  funnel  or  irrigator,  with  a  piece  of  glass 
tubing  between.  The  stomach  tube  (Fig.  17)  should  have  two 
lateral  oval  openings  near  the  point;  and  the  point  should  be  solid 
and  closed  to  prevent  the  collection  of  material  below  the  open- 


Fig.  16. 


-Apparatus  for  gastric  or  colonic  lavage.     A,  stomach  tube;  B,  glass  tube; 
C,  rubber  tube  connection;  D,  glass  irrigator. 


Fig.  17. — Stomach  tube  showing  elongated  lateral  openings. 

ings.  The  edges  of  the  openings  should  be  smooth  and  rounded,  since 
otherwise  particles  of  mucous  membrane  may  be  caught  and  torn 
off.  The  tubes  for  adults  should  be  large,  averaging  Nos.  36  to  38.1 
The  funnel  of  the  lavage  apparatus  (Fig.  18)  should  have  a  capacity 
of  one-half  to  one  liter.  The  small  end  of  the  funnel  must  be  large 
enough  to  permit  the  passage  of  food.  The  rubber  connecting  tube 
must  be  of  the  same  caliber  as  the  stomach  tube,  and  long  enough 


1  Some  confusion  has  resulted  from  the  fact  that  there  are  three  standards  of 
measurement — American,  English  and  French.  To  obviate  error  the  American 
Surgical  Trade  Association  has  adopted  the  French  standard;  so  figures  designating 
the  sizes  of  tubes  will  be  in  the  French  or  standard  metric  scale. 


200 


LAVAGE  OF  THE  STOMACH 


to  reach  from  the  patient's  mouth  to  the  floor  of  the  room.  A 
large  glass  irrigator  is  probably  better  than  the  glass  funnel;  its 
capacity  should  be  at  least  1500  Cc.  (3  pints).  The  irrigator  is 
provided  with  a  handle,  and  has  a  hole  near  the  brim  by  which 
it  may  be  suspended  on  a  hook  (Fig.  16).  The  lower  or  outflow 
opening  should  correspond  in  diameter  to  the  caliber  of  the  stomach 
tube. 

Lavage  with  this  simple  apparatus  is  accomplished  as  follows: 
The  patient  should  be  impressed  by  his  physician  with  the  necessity 
of  the  washing-out  process.  He  should  be  seated  in  a  comfortable 
position,  with  the  body  inclined  slightly  forward,  and  instructed 
to  breathe  regularly  and  deeply.  He* is  taught  to  make  energetic 
movements  of  swallowing  at  the  command  "swallow."  Artificial 
teeth  should  be  removed  before  lavage  is  begun.    The  patient's 


Fig.  18. — Stomach  tube  showing  funnel  connections. 

hands  may  be  employed  in  holding  a  pus  basin  or  other  receptacle 
for  the  purpose  of  cleanliness,  and  in  this  way  any  interference  on 
his  part  may  be  obviated.  The  stomach  tube  should  be  moistened 
with  water,  not  oil,  and  directed  over  the  dorsum  of  the  tongue. 
When  the  end  of  the  tube  reaches  the  posterior  pharyngeal  wall, 
deglutition  begins.  The  tube  slides  easily  over  the  cricoid  cartilage 
into  the  first  section  of  the  esophagus.  When  this  point  is  reached, 
it  is  easy  to  pass  the  tube  on  into  the  stomach.  (The  slight  irrita- 
tion effected  by  moving  the  tube  up  and  down  is  sufficient  to  cause 
the  evacuation  of  large  quantities  of  stomach  contents,  especially 
if  aided  by  pressure  on  the  abdominal  muscles  on  the  part  of  the 
patient.)  A  pint  of  lukewarm  water  should  be  placed  by  an 
assistant  in  the  irrigator  or  funnel,  held  low.  The  tube  of  the 
irrigator  is  meanwhile  stopped  by  means  of  the  fingers  or  clamp  at 
a  short  distance  from  the  free  end,  and  connection  is  duly  made  with 


TECH  NIC  OF  LAVAGE  OF  STOMACH  201 

the  glass  joint  and  the  stomach  tube  in  position.  The  irrigator 
is  then  raised  until  nearly  the  whole  quantity  of  water  has  passed 
into  the  patient's  stomach.  A  small  quantity  of  water  should  be 
left  in  the  irrigator  to  prevent  the  entrance  of  air  into  the  tube. 
The  irrigator  is  now  lowered  to  the  floor  of  the  room,  so  that  the 
stomach  contents,  including  the  water,  may  be  siphoned  off.  It 
should  be  held  in  such  a  manner  that  the  outflowing  liquid  may 
be  visible.  After  noting  the  difference  between  the  outflowing 
fluid  and  the  clear  water  that  entered  the  stomach,  the  contents 
of  the  irrigator  may  be  emptied  in  a  convenient  receptacle.  More 
water  is  allowed  to  enter  the  stomach,  and  the  process  of  lavage 
continues  by  alternately  raising  and  lowering  the  irrigator  until 
the  water  comes  from  the  stomach  clear.  When  lavage  has  been 
completed,  the  stomach  tube  should  be  detached  from  the  irrigator 
and  rapidly  and  gently  withdrawn  from  the  patient's  stomach. 
It  is  important  to  disconnect  the  irrigator  and  tube;  otherwise, 
with  the  former  resting  on  the  floor,  suction  produced  by  the 
siphon  effect  would  tend  to  invaginate  the  mucous  lining  of  the 
stomach  into  the  lateral  openings  of  the  tube  and  thereby  injure 
the  stomach  wall. 

In  the  absence  of  an  assistant,  the  physician  should  fill  the 
irrigator  with  the  required  quantity  of  water  before  commencing 
the  operation.  In  order  to  keep  the  tube  of  the  irrigator  free 
from  air,  it  should  be  compressed  by  means  of  a  large  tube- 
compressor  near  the  glass  connection  as  soon  as  the  water  begins 
to  flow  through.  The  introduction  of  the  stomach  tube  follows. 
The  patient  is  directed  to  keep  the  tube  steady  with  one  hand  at 
his  mouth,  while  with  the  other  he  holds  the  basin.  With  the 
irrigator  resting  on  the  floor,  the  physician  may  connect  it  with 
the  stomach  tube,  loosen  the  tube-clamp  or  compressor,  and  elevate 
the  irrigator. 

I  have  found  my  improved  stomach  tube  and  bulb  (Figs.  1  and  2) 
for  removal  of  the  stomach  contents  a  simple  and  practical  appa- 
ratus for  gastric  lavage.  A  bulbful  of  water  can  be  easily  utilized 
as  described  on  page  71. 

Patients  to  whom  stomach  lavage  must  be  administered  regularly 
and  over  a  long  period  of  time  can  be  taught  to  carry  out  the 
operation  without  the  aid  of  a  physician.  Autolavage  is  a  form 
of  stomach  irrigation  which  has  been  called  physiologic  in  order 
to  distinguish  it  from  the  kind  I  have  just  described;  for  this  the 
use  of  the  stomach  tube  is  not  necessary.  It  is  sufficient  that  the 
patient  drink  four  to  eight  ounces  of  the  irrigating  fluid  and  then 
lie  down  on  his  abdomen,  supported  on  a  somewhat  hard,  resisting 
surface,  across  the  bed  or  on  the  floor.  In  this  position  let  him 
breathe  as  deeply  as  possible.  Fifteen  to  twenty  deep  inspirations 
are  sufficient  to  drive  the  contents  of  the  stomach  through  the 
pylorus.    This  procedure  may  be  repeated  as  often  as  necessary. 


202  LAVAGE  OF  THE  STOMACH 

As  a  rule  the  patient  may  rest  on  his  abdomen  for  five  minutes, 
taking  from  time  to  time  a  number  of  deep  inspirations.  It  has 
been  proved  that  in  this  way  the  stomach  may  be  cleansed  quite 
as  effectively  as  by  the  introduction  of  the  stomach  tube,  provided 
the  pylorus  be  not  occluded.  This  method  has  a  considerable 
advantage  over  the  other,  for  by  it  the  nourishment,  as  prepared 
by  the  stomach,  is  not  lost,  but  follows  the  physiologic  path. 
Besides,  the  patient  will  submit  much  more  readily  to  it  than  to 
the  manipulations  of  lavage  with  the  stomach  tube.  In  order  to 
obtain  the  maximum  effect  from  this  method  of  autolavage,  we 
must  strive  by  all  means  at  our  command  to  free  the  pylorus 
from  all  obstacles  that  interfere  with  its  proper  function.  This  is 
partially  achieved  by  administering  the  fluid  lukewarm. 

Some  patients  may  be  taught  to  use  the  stomach  tube  them- 
selves with  the  aid  of  some  member  of  the  household.  None  but 
the  best  apparatus  should  be  employed.  After  use  it  should  be 
thoroughly  cleansed  by  means  of  hot  water.  In  lavage,  whether 
the  patient  uses  the  apparatus  without  the  aid  of  the  physician, 
or  whether  the  physician  performs  the  operation  upon  a  passive 
patient,  the  simple  apparatus  described  will  be  found  adequate  for 
all  purposes. 

Fig.  19  illustrates  the  apparatus  designed  by  Friedlieb  on  the 
principle  of  suction.  This  instrument  was  designed  to  facilitate 
the  removal  of  obstructing  particles  from  the  stomach  tube  by 
aspiration  by  means  of  a  rubber  bulb.  The  apparatus  of  Strauss 
(Fig.  20)  accomplishes  the  same  purpose  by  means  of  a  double 
bulb.  Both  these  instruments,  in  the  opinion  of  the  author,  are 
unnecessary,  inasmuch  as  clogging  of  the  tube  may  be  prevented 
by  raising  the  irrigator  of  the  apparatus  described  above,  and  thus 
forcing  the  tube  clear  by  water  pressure. 

In  cases  where  the  stomach  is  greatly  dilated  it  is  frequently 
impossible  to  wash  it  out  at  one  sitting.  In  such  cases  lavage 
may  be  better  accomplished  with  the  patient  in  a  recumbent 
posture.  With  the  patient  seated,  the  thoroughness  of  lavage 
may  be  promoted  by  pressing  or  kneading  the  hypogastric  region 
after  the  water  has  been  introduced  into  the  stomach. 

In  cases  where,  owing  to  irritability  of  the  fauces,  it  seems  impos- 
sible to  introduce  the  stomach  tube,  the  difficulty  may  be  overcome 
by  painting  the  fauces  with  a  5-per-cent.  solution  of  cocain  or 
beta-eucain.  Another  effective  and  an  entirely  safe  method  of 
preventing  nausea  from  the  introduction  of  the  stomach  tube  is 
to  freeze  two  or  three  inches  of  the  extremity  of  the  tube  just  before 
introducing  it,  the  object  being  to  secure  light  temporary  anesthesia 
of  the  fauces  and  pharynx  by  means  of  the  cold  rubber.  In  this 
way  cold  is  applied  exactly  where  anesthesia  is  needed,  and  the 
irritability  is  overcome.  Thus  the  tube  may  be  introduced  for 
the  first  time  with  practically  no  gagging,  straining,  or  nausea. 


TECH  NIC  OF  LAVAGE  OF  STOMACH  203 

The  extremity  of  the  tube  may  be  frozen  by  a  few  moments'  spraying 
with  ethyl  chlorid.  The  tube,  of  course,  may  be  chilled  in  other 
ways,  but  the  ethyl  chlorid  is  convenient  and  efficient.  The  tube 
has  been  found  not  to  stiffen  markedly  under  the  influence  of  the 
extreme  cold,  so  that  no  trauma  from  the  frozen  rubber  occurs. 
By  the  time  the  tube  reaches  the  cardia  its  low  temperature  is 
sufficiently  modified  to  obviate  danger  to  the  gastric  mucosa,  even 
though  it  be  allowed  to  remain  in  the  stomach  for  some  time. 


Fig.  19. — Stomach  tube  with  suction  bulb.     (Friedlieb.) 

The  process  of  washing  out  the  stomach  is  not  attended  with 
any  danger.  Temporary  cessation  of  respiration,  of  reflex  origin, 
occurs  in  many  patients  at  the  first  introduction  of  the  tube.  This, 
however,  should  not  occasion  anxiety  on  the  part  of  the  physician, 
since  it  usually  passes  off  readily.  Should  the  patient  become 
alarmed  and  attempt  to  pull  out  the  tube,  an  emphatic  request 
to  "breathe  deeply"  will  overcome  his  fears  and  make  possible 
the  complete  introduction  of  the  tube.  Where  paroxysms  of 
cough,  severe  and  protracted,  supervene,  the  operation  of  lavage 
should  be  interrupted  before  completion. 


204 


LAVAGE  OF  THE  STOMACH 


In  the  presence  of  gastric  hemorrhage,  such  as  occasionally 
occurs  in  cases  of  carcinoma  or  ulcer,  lavage  is  contra-indicated. 
It  is  rarely  employed  in  cases  of  carcinoma  except  as  a  palliative 
measure  when  the  pylorus  is  obstructed.  In  gastric  ulcer  it  is  apt 
to  do  a  great  deal  of  harm,  and  should  never  be  employed  when 
there  is  any  indication  of  gastric  hemorrhage.  In  cases  of  nervous 
dyspepsia  lavage  sometimes  transforms  the  patient  into  a  gastric 
hypochondriac,  a  most  lamentable  condition.  In  the  majority  of 
nervous  cases  lavage  is  contra-indicated.  Surface  hemorrhage  may 
take  place  in  catarrh  due  to  gastritis;  when  such  hemorrhages  are 
of  a  pronounced  character  the  irrigations  should  be  discontinued . 

Not  over  2  per  cent,  of  cases  of  gastric  disease,  or  of  patients 
presenting  symptoms  suggestive  of  gastric  disease,  require  lavage 
as  an  element  of  treatment. 


Fig.  20. — Suction  tube  with  double  bulb.     (Strauss.) 

Gastroenterologists  differ  in  their  views  regarding  the  time 
stomach  irrigations  should  be  administered.  I  consider  it  advis- 
able in  cases  where  there  is  no  engorgement,  for  example  in  cases 
of  chronic  gastritis,  when  we  wish  to  remove  mucous  secretion, 
to  perform  irrigation  in  the  morning  while  the  stomach  is  empty. 
In  cases  of  stenosis  of  the  pylorus,  with  stagnant  masses  of  food  in 
the  stomach,  the  best  time  for  lavage  is  in  the  evening  shortly 
before  the  evening  meal. 

The  duration  of  the  treatment  must  be  determined  in  each  case 
by  the  conditions  present.  In  cases  where  it  is  impossible  to  deter- 
mine this  point,  as  in  inoperable  carcinoma,  it  is  advisable  to  have 
the  patient  wash  out  his  own  stomach.  A  medicated  lavage  may 
follow  the  cleansing  lavage.  The  indications  for  the  different 
kinds  of  lavage  are  given  under  the  respective  diseases. 


THE  STOMACH  DOUCHE  205 

In  lavage  preliminary  to  surgical  operation  on  the  stomach,  care 
should  be  exercised  that  no  water  remains  in  the  viscus.  In  lavage 
kept  np,  as  described,  until  the  washings  return  clear,  a  further 
quantity  of  water  can  be  dislodged  by  placing  the  patient  in  the 
Trendelenburg  position;  the  flow  will  continue  until  the  tube  is 
withdrawn  from  the  cardiac  orifice  and  the  stomach  is  entirely 
emptied. 

THE  STOMACH  DOUCHE. 

Douching  of  the  stomach  should  be  employed  only  when  the 
viscus  is  empty.  The  sole  object  is  to  irrigate  the  mucous  mem- 
brane, either  with  plain  water  or  with  medicated  solutions.  The 
douching  may  be  performed  by  means  of  Rosenheim's  tube  (Fig.  21) . 
This  instrument  consists  of  a  stomach  tube  having  at  its  gastric 
extremity  a  number  of  small  openings,  from  one  to  two  millimeters 
in  diameter.  Water  is  permitted  to  flow  through  the  tube  into  the 
stomach  so  that  all  parts  of  the  gastric  mucosa  are  irrigated  through 
the  numerous  small  openings.  In  the  process,  however,  one  or 
more  of  the  fenestra?  are  frequently  blocked  by  mucus. 


■\j w <J ^ <_/- 


.r^ r^> r\ r\_ r\. 


Fig.  21. — Perforated  tube.     (Rosenheim.) 

In  Richter's  method  of  removing  mucus  by  irrigation,  an  ordinary 
stomach  tube  is  introduced  to  the  extent  of  40  centimeters,  or  to  the 
cardia  of  the  empty  stomach.  The  irrigating  fluid,  under  pressure, 
is  allowed  to  pour  into  the  stomach,  douching  the  collapsed  walls. 
While  a  small  quantity  of  water  yet  remains  in  the  irrigator  the 
tube  is  pushed  into  the  stomach  so  that  the  fenestra?  become 
immersed  in  the  water  there;  the  irrigator  is  then  lowered  to  the 
floor  and  the  contents  are  siphoned  out.  The  tube  is  then  with- 
drawn to  the  cardia,  and  the  process  is  repeated  as  often  as  necessary 
to  cleanse  the  stomach  of  the  mucous  secretion. 

Einhorn's  apparatus  (Fig.  22)  consists  of  a  tube  (A)  about 
60  cm.  in  length  and  1  cm.  in  diameter,  having  at  the  gastric 
extremity  a  cylinder  of  hard  rubber  shaped  like  a  capsule  (B). 
This  capsule  has  numerous  minute  openings,  and  at  the  lower  end 
a  larger  round  aperture.  Within  the  hard  rubber  capsule  is  an 
aluminum  ball  (C),  which  acts  as  a  valve  and  closes  the  opening 
in  the  extremity  of  the  capsule  when  the  tube  is  introduced  and 
the  irrigating  fluid  forced  into  it.  The  water  enters  the  stomach 
by  way  of  the  small  openings.  The  return  flow,  however,  forces 
the  ball  from  the  lower  opening,  and  the  entering  liquid  keeps 
this  opening  clear  until  the  stomach  is  completely  emptied.    The 


206 


LAVAGE  OF  THE  STOMACH 


defects  of  the  Rosenheim  tube  are  remedied  in  Einhorn's  apparatus. 
Preparatory  to  the  entrance  of  the  irrigating  fluid,  Einhorn's 
tube  should  be  introduced  only  a  short  distance  below  the  cardia; 
but  to  facilitate  the  return  flow  of  water  and  mucus  it  should  be 
pushed  in  10  to  12  centimeters  farther. 

Turck  has  devised  a  double-flow  stomach  douche,  consisting 
of  two  tubes  cemented  together;  one  tube  is  longer  than  the  other, 
which  enables  it  to  reach  the  fundus  while  the  shorter  tube  is 


Fig.  22.— Apparatus  for  stomach  douche.     (Einhorn.)     A,  stomach  tube;  B,  hard 
rubber  capsule;  C,  aluminum  ball. 

near  the  cardia.  The  latter  has  at  its  end  a  metal  ball,  finely  per- 
forated; the  water  passing  through  acts  as  a  fine  needle  spray  or 
douche  on  the  mucous  membrane  of  the  stomach.  The  longer  tube 
carries  the  water  back,  so  that  the  stomach  is  not  distended  with 
too  great  a  quantity  of  water  at  any  one  time. 

Chase  has  devised  an  improved  tube  (Fig.  23),  by  means  of 
which  (1)  the  gastric  contents  can  be  removed  by  aspiration,  (2) 
the  stomach  washed  or  douched,  (3)  and  inflation  of  the  stomach 
effected,  without  making  a  connection  or  disconnection  of  the 


the  stommii  not  <iii: 


207 


apparatus  and  without  the  use  of  stopcock  or  shut-off.  By  sub- 
stituting a  "Rosenheim"  douching  tube  the  stomach  may  be 
douched  as  recommended  by  Rosenheim.  Chase's  apparatus 
consists  of  (1)  an  Ewald  stomach  tube  proper,'^30  inches  long, 


Fig.  23. — Stomach  tube.     (Chase.) 


marked  at  22  inches  from  its  distal  end  with  a  white  band;  (2)  an 
adjustable  saliva  shield,  to  prevent  saliva  from  flowing  down 
the  tube;  (3)  a  glass  connector;  and  (4)  a  30-inch  connecting  tube, 
to  which  is  attached  a  strong  valveless  bulb  of  3  ounces  (90  Cc.) 
capacity. 


CHAPTER  X. 
MASSAGE— ELECTRICITY. 

MASSAGE  OF  THE  STOMACH. 

Massage  consists  of  a  systematic  manipulation  for  definite 
therapeutic  ends.  The  success  of  the  process  depends  upon  the 
precise  performance  of  certain  well  understood  movements  of  the 
hands  of  the  physician.  The  operator  in  applying  the  treatment 
should  keep  in  mind  the  particular  end  to  be  accomplished  in  the 
individual  patient.  The  several  movements  consist  of  various 
applications  of  rubbing,  kneading,  stretching,  and  pinching  of 
the  muscles.  The  two  hands  must  be  directed  with  intelligence 
and  skill. 

Indications. — Massage  is  of  greatest  value  in  diseases  due  to 
altered  metabolism,  and  in  those  in  which  the  powers  of  digestion, 
absorption  or  assimilation  are  defective.  Nutrition  may  be  pro- 
foundly influenced  by  regular  and  continued  massage.  Among  the 
special  indications  for  this  mechanical  treatment  are: 

1.  Relaxed  musculature  which  may  be  strengthened  by  passive 
exercise,  and  connective-tissue  adhesions  that  require  to  be  relaxed 
or  broken  up. 

2.  Retention  of  gastric  contents  for  an  abnormally  long  time  in 
the  alimentary  tract.  This  applies  more  particularly  to  the  intes- 
tine than  to  the  stomach,  where  under  some  conditions  mechanical 
treatment  may  cause  direct  injury. 

3.  Certain  forms  of  dilatation  due  to  pyloric  stenosis.  In  the 
presence  of  marked  fermentative  processes  massage  should  not  be 
employed,  owing  to  the  possibility  of  propelling  fermenting  masses 
into  the  intestine,  where  the  conditions  for  the  growth  and  multipli- 
cation of  bacteria  are  much  more  favorable  than  in  the  stomach. 

4.  In  certain  sensory  forms  of  nervous  dyspepsia,  where  sensa- 
tions of  pressure  or  pain  are  present,  massage  may  be  tentatively 
employed. 

5.  The  mechanical  treatment  of  the  abdomen  has  given  favorable 
results  in  cases  of  primary  intestinal  atony  and  constipation  tending 
to  secondary  disturbances  of  the  gastric  function. 

Contra-indications.- — Massage  is  contra-indicated  in  all  recent 
cases  of  ulcer  with  adhesions,  in  which  cases  even  its  cautious 
application  may  cause  a  perforation  of  the  ulcer  into  a  neighboring 
organ,  with  the  well-known  disastrous  effects.  It  should  not  be 
employed  in  any  residual  inflammatory  conditions  of  the  gastro- 


MASSAGE  OF  THE  STOMACH  209 

intestinal  tract,  nor  in  the  acute  inflammatory  stage  in  which  there 
are  symptoms  of  meteorism  or  fever.  It  should  be  avoided  in  the 
presence  of  abdominal  pain.  Patients  with  hyperchlorhydria  or 
hypersecretion  are  not  to  be  subjected  to  massage,  owing  to  the 
danger  of  inducing  ulcer  of  the  stomach.  Massage  is  contra-indi- 
cated in  dilatation  of  the  stomach  in  which  organic  stenosis  is 
present.  If  the  gastric  muscles  are  spontaneously  very  active,  if  the 
peristaltic  movements  are  pronounced  and  frequent  or  sometimes 
as  if  in  a  tetanic  condition,  or  if  the  stomach  feels  under  the  hand 
somewhat  like  a  contracted  uterus  after  birth  (muscular  rigidity), 
the  massage  treatment  should  not  be  employed. 

Carcinoma  of  the  stomach  is  always  an  absolute  contra-indi- 
cation  for  massage,  owing  to  the  possibility  of  exciting  to  rapid 
growth  a  tumor  that  has  hitherto  been  latent.  Massage  in  the 
treatment  of  patients  above  forty  years  of  age  in  whom  the  symp- 
toms of  gastric  disease  have  appeared  suddenly,  unless  malignancy 
can  be  positively  excluded,  should  be  performed  with  great  caution. 
Inconsiderate  massage  of  the  abdomen  may  stimulate  a  latent 
intestinal  carcinoma  to  rapid  growth  and  metastasis.  Dormant 
gastric  ulcers  may  be  awakened  by  massage  to  harmful  activity. 
Whenever  the  test  for  occult  blood  in  the  feces  is  positive,  massage 
is  contra-indicated.  The  physician  should  examine  McBurney's 
point  and  the  region  of  the  gall  bladder  for  possible  inflammation 
before  attempting  massage  of  the  abdomen.  A  history  of  gastralgia 
at  any  time,  especially  before  or  after  pregnancy,  increases  the 
probability  of  latent  gallstone  disease,  contra-indicating  massage. 
There  are  various  affections  of  the  liver,  spleen  and  pancreas  which 
contra-indicate  abdominal  massage.  In  fact,  abdominal  pain  of  any 
kind  contra-indicates  it. 

Massage  may  be  applied  when  the  stomach  is  either  full  or 
empty.  When  the  stomach  is  filled,  massage  is  indicated  in  cases 
of  spasm  of  the  pylorus  and  in  mild  cases  of  organic  stenosis,  the 
purpose  being  to  propel  the  macerated  food  into  the  intestine.  It 
should  be  performed  three  or  four  hours  after  the  chief  meal. 

Technic. — The  technic  of  the  mechanical  treatment  must  vary 
according  to  the  object  to  be  accomplished.  When  the  object  is 
passive,  evacuation  of  the  stomach  contents  through  the  pylorus, 
insert  the  right  hand  deeply  in  the  loose  flesh  on  the  left  side,  grasp- 
ing a  portion  of  the  stomach  between  the  thumb  and  the  four  fingers, 
and  by  a  pushing  motion  at  the  fold  move  the  gastric  contents 
toward  the  pylorus.  The  left  hand  advances  toward  the  pyloric 
exit,  beginning  near  the  thumb  of  the  right  hand.  The  patient 
should  be  lying  in  an  inclined  position,  the  body  sloping  toward 
the  right  side.  These  movements  on  the  part  of  the  physician 
should  be  repeated  as  often  as  necessary.  The  massage  move- 
ments on  the  full  stomach  should  be  concluded  by  short  tapping 
strokes,  technically  known  as  tapotement.  Both  hands  of  the 
14 


210  MASSAGE— ELECTRICITY 

operator  are  placed  vertically,  midway  between  supination  and 
pronation,  over  the  part  to  be  treated;  they  are  then  completely 
pronated  and  the  stomach  is  tapped  with  the  fingers  widely  sepa- 
rated. The  movements  should  be  executed  rapidly,  but  too  great 
force  should  be  avoided.  Tapotement,  as  it  is  called,  has  a  stimu- 
lating effect  upon  the  musculature  of  the  stomach. 

Petrissage  is  performed  in  the  following  manner:  The  operator 
stands  at  the  right  side  of  the  patient  and  presses  with  the  right 
hand  in  the  gastric  region  in  the  middle  line.  The  pressure  is 
deep,  to  reach  the  spinal  column,  thereby  dividing  the  stomach  into 
two  equal  parts — one  the  fundus,  the  other  the  pylorus.  The 
food  mixture  compressed  in  the  pyloric  half  is  then  to  be  pushed 
toward  the  pylorus  so  that  it  may  act  somewhat  like  a  bougie, 
dilating  the  pyloric  exit. 

On  account  of  the  deep  situation  of  the  stomach  and  the  slight 
resistance  of  the  deep  plane  on  which  it  rests,  only  a  limited  portion 
of  the  viscus  can  be  reached  in  the  dorsal  decubitus.  For  a  dilated 
stomach  the  author  kneads  at  first  from  left  to  right  with  patient 
on  back,  knees  bent  and  head  raised.  After  a  few  minutes  he  has 
the  patient  lie  on  the  right  side,  and  petrissage  is  performed  with 
both  hands  alternately,  from  pylorus  toward  cardia.  Gentleness 
is  necessary  during  the  seance.  The  operation  should  last  about 
fifteen  minutes  for  the  stomach  alone,  and  fifteen  minutes  more 
for  the  intestine  if  there  is  constipation.  The  treatment  should 
be  given  two  or  three  hours  after  a  meal.  The  beneficial  effect 
most  frequently  manifests  itself  first  by  a  returning  appetite, 
then  by  the  disappearance  of  the  rumblings,  eructations,  gastric 
pains,  headache,  vertigo,  etc.  At  the  beginning  the  diet  must  be 
light  and  limited  in  quantity.  Massage  is  of  benefit  in  chronic 
gastritis,  nervous  dyspepsia,  gastralgia  due  to  neurasthenia  or 
anemia,  and  pylorospasm,  but  it  may  do  harm  in  ulcers  or  tumors 
of  the  pylorus.  The  massage  movements  are  not  always  successful 
in  expelling  the  contents  of  the  stomach  into  the  duodenum. 

For  improving  the  tone  of  the  empty  stomach,  Credes  method 
may  be  applied.  This  well-known  process  is  employed  frequently 
in  delivering  the  placenta — by  expression,  just  as  a  stone  is  removed 
from  a  cherry.  By  means  of  the  expression  movement  in  the  line 
of  the  transverse  axis  of  the  stomach,  we  endeavor  to  propel  the 
residue  of  gastric  contents  into  the  duodenum. 

Massage  movements  may  be  facilitated  by  lubricating  the 
epigastric  region  with  pure  olive  oil  or  with  glycerin.  By  the  use 
of  glycerin,  oily  stains  on  the  clothing  may  be  avoided.  One-per- 
cent, salicylic  acid  added  to  the  glycerin  will  prevent  irritation  of 
the  skin. 

Wegele  recommends  the  employment  of  medicated  lavage  in 
conjunction  with  massage  in  various  forms  of  chronic  gastritis 
and  in  hyperacidity,  for  the  relief  of  hyperesthesia  of  the  mucous 


INTESTINAL  MASSAGE  211 

membrane,  or  nervous  gastralgia.  The  medication  he  employs 
includes:  physiologic  salt  solution;  1-per-cent.  solution  of  ichthyol; 
1.5-per-cent.  Carlsbad  salt  solution;  5- or  6-per-cent.  suspension  of 
bismuth  subnitrate;  1-  or  2-per-cent.  silver  nitrate  solution,  followed 
by  rinsing  with  normal  saline  solution;  decoctions  of  bitter  tonics; 
and  disinfecting  solutions.  The  fluids  are  either  swallowed  or  intro- 
duced by  means  of  the  stomach  tube. 

Massage  of  the  stomach  should  never  be  delegated  to  a  layman 
to  perform,  nor  should  it  be  undertaken  by  any  one  who  is  not 
thoroughly  conversant  with  the  principles  of  the  treatment. 

Vibratory  massage  is  of  little  or  no  value  in  the  treatment  of 
diseases  of  the  stomach.  It  is  of  value  in  neurasthenic  conditions, 
when  it  should  be  applied  to  the  spine.  It  should  never  be  used 
directly  on  the  stomach  in  any  diseased  condition  of  that  viscus. 
The  pylorus  will  open,  according  to  Abrams,  from  pressure  over 
the  fifth  dorsal  vertebra.  Either  pressure  or  percussion  at  this 
location  suffices. 

INTESTINAL  MASSAGE. 

Physical  exercises  perform  an  important  role  in  strengthening 
the  abdominal  walls  while  they  add  tone  to  the  musculature  of  the 
intestinal  tract. 

Massage  of  the  abdomen  and  intestine  is  recommended  along 
with  gastric  massage.  The  purpose  of  abdominal  massage  is  to 
strengthen  the  relaxed  abdominal  walls,  stimulate  peristalsis,  and 
improve  the  circulation  in  the  abdominal  vessels  by  stimulation 
of  the  sympathetic  nervous  system.  The  technic  of  abdominal 
massage  is  as  follows:  The  patient  should  be  placed  on  a  firm 
couch  or  table,  with  his  head  slightly  elevated;  the  lower  extremi- 
ties are  flexed  at  the  hips  and  knees.  The  physician  occupies  a 
position  to  the  right  of  the  patient.  Massage  should  be  commenced 
very  gently,  especially  in  the  case  of  patients  on  whom  it  is  being 
performed  for  the  first  time,  in  order  to  prevent  rigidity  of  the 
abdominal  walls — which  renders  deep  massage  practically  impos- 
sible. Both  hands  should  be  laid  upon  the  abdomen  and  slight 
stroking  movements  made  (rotating  effleurage).  Concentric  circles 
should  be  made  in  the  direction  of  the  hands  of  the  clock.  The 
movements  should  be  begun  at  the  symphysis,  proceeding  upward 
and  then  over  the  entire  abdomen  (Fig.  24).  These  movements 
are  designed  to  overcome  the  tension  of  the  abdominal  walls; 
in  particularly  stout  patients  the  circular  movements  may  be 
followed  by  kneading  of  the  abdominal  walls  (petrissage).  Deep 
kneading  of  the  intestine  should  follow,  the  purpose  being  to 
stimulate  intestinal  peristalsis  and  thereby  loosen  impacted  fecal 
matter.  Both  hands  should  follow  the  direction  of  the  intestine 
through  the  abdominal  walls;  zigzag  movements  to  and  fro  are  to  be 
made  (Fig.  25). 


212 


MASSAGE— ELECT  Rl  CITY 


Fig.  24. — Abdominal  massage,  first  movement.     (Hoffa.) 


Fig.  25. — Abdominal  massage,  second  movement.     (Hoffa.) 


INTESTINAL  MASSAGE 


213 


Deep  petrissage  should  involve  the  whole  abdomen,  affecting 
particularly  the  median  portion  of  the  intestinal  tract,  namely, 
the  ileum.  The  operator  should  next  proceed  toward  the  large 
intestine.  The  movements  are  made  first  by  the  right  hand,  which 
is  dorsally  flexed  and  placed  in  the  right  pubic  fossa  at  the  begin- 
ning of  the  ascending  colon  (Fig.  26).  Pressure  is  made  as  deeply 
as  possible,  and  in  order  to  augment  it  the  points  of  the  fingers  of 
the  left  hand  should  be  pressed  upon  those  of  the  right.  The  move- 
ment is  first  upward  toward  the  hepatic  flexure,  then  transversely 
below  the  arch  of  the  ribs  toward  the  left  side,  and  finally  downward 
so  that  the  stroke  penetrates  deeply  into  the  left  iliac  fossa.  The 
pressure  then  ceases  and  the  hands  glide  over  the  bladder  back  to 


Fig.  26. — Abdominal  massage,  third  movement.     (Hoffa.) 


the  right  iliac  fossa,  from  which  point  the  stroking  of  the  large 
intestine  should  be  repeated  several  times.  A  few  rotating  effleu- 
rage  movements  of  a  soothing  nature  should  be  performed.  Then 
should  follow  rotating  petrissage  of  the  large  intestine.  With  the 
left  hand  placed  over  the  right,  the  fingers  of  both  hands  should 
push  with  a  rotating  motion  into  the  cecal  region,  the  finger  ends 
pointing  toward  the  chest.  The  pressure  should  be  light  at  first,  but 
gradually  increased  until  the  whole  course  of  the  large  intestine  is 
thoroughly  massaged  with  this  rotating  petrissage. 

The  muscles  of  the  intestinal  tract  should  then  be  subjected  to 
slight  stimulating  "  tapotement."  While  executing  these  latter 
movements  the  hands  should  be  held  so  that  the  thumb  is  approxi- 


214  MASSAGE^ELECTRICITY 

mated  to  the  index  finger,  and  the  other  fingers  are  slightly  flexed. 
The  abdomen  should  be  slightly  tapped  in  all  directions.  More 
vigorous  tapotement  may  be  performed  with  the  dorsal  surface  of 
the  flexed  fingers,  the  middle  finger  being  elevated  slightly  above 
the  others.  This  procedure  may  be  advantageously  followed  by 
shaking  motions  with  the  right  hand  placed  flat  on  the  central 
part  of  the  abdomen,  the  fingers  of  the  operator  being  spread 
widely  apart. 

In  chronic  constipation,  by  careful,  continued  and  frequently 
repeated  massage  of  the  intestine  the  bowel  may  be  emptied,  the 
weakened  intestinal  muscles  stimulated,  and  the  secretions — nearly 
always  deficient  in  this  disease — brought  back  in  normal  quantity. 
When  the  patients  have  begun  to  improve,  a  careful  and  punctual 
habit  of  defecation  should  be  inculcated,  that  a  permanent  cure  may 
result.  Before  attempting  to  use  massage  for  chronic  constipation 
it  is  necessary  to  empty  the  bowel  thoroughly  by  enemata,  lest 
there  be  some  retention  of  impacted  feces  in  the  colon,  a  condition 
which  cannot  always  be  excluded  by  a  daily  evacuation  by  means  of 
purgatives.  Should  abdominal  massage  be  applied  while  these 
impacted  masses  are  in  the  bowel,  inflammatory  disturbances  might 
result.  A  preliminary  Roentgen-ray  examination  will  reveal  the 
exact  position  of  the  colon,  enabling  the  operator  to  follow  its 
course  with  certainty. 

The  sympathetic  nerve  plexuses  may  be  reached  by  massage. 
In  order  to  get  at  the  celiac  plexus  the  ends  of  the  fingers  are  placed 
lightly  upon  the  abdomen  midway  between  the  umbilicus  and  the 
ensiform  cartilage;  gradual  pressure  should  then  be  exerted,  pene- 
trating more  deeply  with  each  respiratory  retraction  of  the  dia- 
phragm until  the  spinal  column  is  reached,  when  motions  of  a 
vibrating  or  trembling  nature  should  be  executed. 

The  splanchnic  plexus  is  reached  in  the  same  manner,  except 
that  the  straight  fingers  should  penetrate  toward  the  spinal  column 
midway  between  the  umbilicus  and  the  symphysis. ' 

Abdominal  massage  may  be  followed  with  advantage  by  a  general 
vibration  of  the  abdomen,  given  gently  by  means  of  an  electric 
vibratory  apparatus. 

The  stomach,  bladder  and  rectum  should  be  emptied  before 
massage  of  the  abdomen  is  begun. 

ELECTRIC  TREATMENT. 

The  use  of  electricity  in  the  treatment  of  gastric  and  intestinal 
disorders  has  been  highly  recommended  by  various  writers,  but 
the  general  practitioner  rarely  avails  himself  of  this  therapeutic 
agent. 

To  Einhorn  belongs  the  credit  of  bringing  electrization  of  the 
stomach  within  the  range  of  practical  therapeutics,  both  by  experi- 


ELECTRIC  TREATMENT  215 

incut  ami  by  the  invention  of  his  deglutible  stomach  electrode. 
From  an  extensive  study  of  the  physiologic  effects  of  direct  elec- 
trization of  the  stomach,  Einhorn  draws  the  following  conclusions: 

1.  Direct  faradization  of  the  stomach  increases  gastric  secretion 
during  the  application  and  also  for  a  short  time  afterward. 

2.  Direct  galvanization  of  the  stomach,  with  the  negative  pole 
within  the  organ,  in  most  instances  diminishes  gastric  secretion. 

3.  Direct  faradization  as  well  as  galvanization  of  the  stomach 
increases  its  absorbent  faculty. 

His  conclusions  as  to  the  therapeutic  value  of  electricity  in  the 
treatment  of  gastric  diseases  are : 

1.  Direct  gastric  electrization  is  a  potent  agent  in  the  field  of 
chronic  (non-malignant)  diseases  of  the  stomach. 

2.  Direct  gastrofaradization  proves  to  be  useful  in  many  ways 
in  the  majority  of  chronic  diseases  of  the  stomach. 

The  favorable  results  appear  very  promptly  in  cases  of  gastric 
dilatation  not  due  to  pyloric  obstruction.  Here  the  benefit  is 
apparent  whether  there  is  subacidity  or  hyperacidity.  Cases  of 
relaxation  of  the  cardia  (eructation)  and  of  relaxation  of  the 
pylorus  (presence  of  bile  in  the  stomach)  have  been  very  favorably 
influenced  by  faradization. 

3.  Gastrogalvanization  is  almost  a  sovereign  means  for  treating 
severe  and  very  obstinate  gastralgias,  no  matter  whether  the  pain 
be  of  nervous  origin  or  from  cicatricial  ulcer. 

4.  Gastrogalvanization  exerts  a  favorable  influence  on  several 
affections  of  the  heart  complicated  with  gastralgia. 

The  good  results  obtained  from  electric  treatment  of  the  stomach 
would  seem  to  indicate  that  the  sensory  and  secretory  nerves  have 
been  stimulated,  although  Freund  made  a  study  of  the  effect  of  the 
electric  current  on  gastric  secretion  and  found  that  it  was  absolutely 
negative,  the  only  result  being  the  production  of  a  small  amount 
of  a  mucoid  secretion  strongly  alkaline  in  reaction.  He  concludes 
that  food  is  the  only  stimulus  which  will  cause  the  gastric  glands  to 
act. 

Indications. — Electric  treatment  of  the  stomach  is  indicated  in 
cases  of  atony  and  ptosis  of  the  stomach  and  its  sequela?.  Favor- 
able results  may  be  expected  in  the  absence  of  organic  stenosis  of 
the  pylorus.  Faradization  is  especially  recommended  in  cases  of 
gastric  atony.  A  further  indication  for  electric  treatment  is  fur- 
nished by  those  neuroses  of  the  stomach  which,  in  the  absence  of 
marked  objective  symptoms,  are  to  be  considered  as  functional 
derangements.  As  examples  we  have  paresthesias,  gastralgias, 
pylorospasm,  nervous  vomiting,  bulimia,  and  anorexia.  In  these 
cases  the  galvanic  current  is  employed  with  good  results,  particu- 
larly in  cases  of  gastralgia,  hysterical  vomiting,  and  the  vomiting 
of  pregnancy.  The  applications  are  made  both  intraventricularly 
and  extraventricularly.  Good  results  have  also  been  secured  with 
intra-  and  extraventricular  faradic  treatment  of  such  conditions. 


216 


MASSAGE—ELECTRICITY 


As  a  rule  the  intraventricular  application  of  the  electric  current 
is  more  successful  than  the  extraventricular.  The  latter  is  especially 
adapted  to  those  cases  in  which  the  object  is  to  exert  an  influence 
on  the  abdominal  muscles  as  well  as  on  the  stomach  itself.  Since 
the  normal  gastric  mucous  membrane  is  not  sensitive,  electric 
treatment  of  the  interior  of  the  stomach  is  easily  accomplished. 

Intraventricular  Electrization  (Application  of  Electricity  to  the 
Interior  of  the  Stomach). — Several  apparatus  are  at  our  disposal 
for  the  application  of  electricity  to  the  stomach.  First  of  all  there 
is  the  electric  sound  of  Boas  (Fig.  27).  This  is  a  stomach  tube, 
with  numerous  small  perforations  at  its  lower  extremity,  contain- 
ing in  its  interior  a  spiral  of  platinum  that  is  held  in  place  by  a 
clamp  at  the  upper  opening  of  the  tube.  Water  can  be  introduced 
into  or  withdrawn  from  the  stomach  by  means  of  this  sound  while 
the  latter  remains  in  situ. 


Fig.  27. — Stomach  electrode.     (Boas.) 


Wegele  makes  use  of  an  ordinary  stomach  tube  with  a  glass 
joint  at  its  oral  end.  By  means  of  a  rubber  tube  a  funnel  can  be 
joined  to  it,  if  necessary,  and  the  stomach  either  rilled  with  or 
evacuated  of  water.  A  fine  metal  wire,  ending  in  a  button,  is 
introduced  into  the  stomach  tube  so  that  the  button  reaches  to 
within  one  centimeter  of  the  stomach  end  of  the  tube.  The  exact 
length  of  wire  to  be  introduced  into  the  tube  is  adjusted  by  a  set 
screw  (Fig.  28). 

A  third  apparatus  has  been  described  by  Einhorn  (Fig.  29). 
A  metal  button  within  a  perforated  hard  rubber  capsule  is  joined 
by  a  fine  transmission  wire  to  an  electric  battery.  The  transmission 
wire  is  insulated  by  a  thin  rubber  tubing.  In  using  this  apparatus 
the  patient  swallows  the  hard  rubber  capsule  with  a  little  water. 


ELECTRIC  TREATMENT 


217 


Lockwood  has  modified  Einhorn's  gastric  electrode  by  making 
the  following  changes:  The  capsule  is  reduced  in  size  to  the  dimen- 
sions of  an  ordinary  five-grain  gelatin  capsule.     To  the  metal  button 


c 


s 


£ 


-a 


Fig.  28. — Stomach  electrode.     (Wegele.) 

within  the  capsule  is  attached  a  spiral  of  flat  steel,  the  flexibility 
of  which  corresponds  to  that  of  an  ordinary  stomach  tube.  This 
spiral  is  covered  by  thin  rubber  tubing,  and  is  tipped  with  a  bind- 
ing pin  for  connection  with  the  battery. 


Fig.  29. — Intragastric  electrode.     (Einhorn.) 


Such  an  electrode  can  be  easily  introduced  into  the  stomach 
without  discomfort.  The  small  size  of  the  capsule  allows  of  its 
ready  passage,  while  the  spiral  attachment  is  sufficiently  resistant 
to  enable  the  operator  to  push  the  capsule  along,  just  as  a  stomach 
tube  is  introduced. 


218 


MASSAGE—ELECTRICITY 


Stockton  has  devised  an  instrument  which  is  a  combined  stomach 
tube  and  electrode  (Fig.  30) .  An  ordinary  soft  rubber  stomach  tube, 
28  inches  long,  "is  coupled  by  means  of  a  ground  steel  joint  to  three 
feet  of  rubber  tubing,  terminating  in  the  ordinary  funnel.  Through 
this  the  stomach  is  emptied  in  the  usual  way.  Then  the  rubber 
tubing  is  disconnected  at  the  coupling  without  removing  the 
stomach  tube  itself  from  the  stomach.  There  is  now  introduced 
through  the  stomach  tube,  in  situ,  a  spiral  electrode,  which,  when 
in  place,  completely  closes  the  proximal  opening  of  the  tube  by 
a  ground  steel  plug,  the  distal  extremity  of  the  wire  being  at  the 
upper  of  the  two  fenestra?  at  the  lower  end  of  the  tube.  This 
arrangement  prevents  the  metal  point  from  touching  the  mucous 
membrane  of  the  stomach. 

Before  the  introduction  of  the  electric  sound  the  patient  drinks 
a  large  tumblerful  of  lukewarm  water,  or  the  water  may  be  intro- 
duced by  means  of  the  tube.    The  fluid  distributes  the  current  to 


Fig.  30. — Combined  stomach  tube  and  electrode.     (Stockton.) 

the  gastric  wall.  For  the  purpose  of  faradization  a  large  plate 
electrode  is  placed  either  on  the  epigastric  region  or  on  the  back, 
to  the  left  of  the  seventh  dorsal  vertebra.  Weak  currents  are 
employed  at  first,  the  current  being  gradually  increased  to  such  a 
force  that  the  patient  is  just  able  to  bear  it.  Rather  forcible  currents 
are  permissible.    The  duration  of  the  seance  is  about  ten  minutes. 

The  negative  electrode  is  introduced  into  the  stomach  for  the  pur- 
pose of  galvanization.  A  broad  plate  electrode  is  applied  in  the  same 
manner  as  when  faradizing,  the  location  being  altered  if  necessary; 
the  current  is  begun  slowly  and  carried  up  to  the  strength  of  15 
to  20  milliamperes,  and  is  then  slowly  diminished.  The  duration 
of  the  treatment  is  from  eight  to  ten  minutes. 

Galvanofaradization  is  likewise  applicable.  Intraventricular 
faradization  is  especially  recommended  in  atony,  relaxation  of 
the  pylorus,  and  paresis  of  the  cardia  from  disturbances  in  the 
cerebral  nerve  centers  or  from  neurasthenia.     Internal  galvaniza- 


ELECTRIC  TREATMENT  219 

tion  is  especially  worthy  of  application  in  gastralgias,  chronic  hyper- 
secretion, and  derangements  of  the  autonomic  nervous  system. 
The  internal  electric  treatment  of  the  stomach  is  the  sovereign 
remedy  for  nervous  vomiting. 

Extraventricular  Electrization. — Two  large  rectangular  plate  elec- 
trodes are  to  be  employed  for  this  purpose.  One  of  them,  well 
moistened,  is  to  be  applied  to  the  region  of  the  stomach,  the  other 
to  the  back.  The  gastric  electrode  is  put  on  firmly  and  pressed 
in  deeply,  making  the  distance  between  the  two  plates  as  small  as 
possible.  Another  arrangement  of  electrodes  is  as  follows:  Of 
two  large  curved  plates,  the  larger  one  (300  millimeters  square)  is 
applied  from  the  front  of  the  abdomen  to  the  spinal  column,  and 
the  other  in  a  similar  way  on  the  opposite  side.  The  distance 
between  the  edges  of  the  two  electrodes  must  be  at  least  one  or  two 
centimeters. 

While  faradizing,  weak  currents  are  used  to  begin  with;  these  are 
gradually  increased,  as  in  intraventricular  faradization,  to  the  limit 
of  the  patient's  tolerance.  In  sensitive  persons  treatment  may  be 
interrupted  by  a  short  pause  every  half-minute. 

An  electric  roller  cylinder  may  be  employed  instead  of  the  anterior 
electrode;  this  is  rolled  to  and  fro  in  the  region  of  the  stomach 
without  interruption,  and  thus  effects  an  even  electric  massage  of 
the  stomach.    The  electric  brush  may  likewise  be  used  anteriorly. 

While  galvanizing,  the  current  is  gradually  increased  to  15  to 
20  milliamperes,  it  being  a  matter  of  indifference  whether  the 
anode  is  situated  in  front  or  behind.  The  duration  of  the  treatment 
is  five  minutes. 

High-frequency  currents  have  been  extensively  used  in  the 
treatment  of  diseases  of  the  digestive  organs.  A  million  volts  can 
be  made  to  permeate  the  body  by  a  course  of  autocondensation. 
As  a  result,  metabolism  is  increased  and  muscular  contractions 
stimulated,  while  neural  and  glandular  excitement  is  quieted. 
The  effects  upon  the  intestine  seem  to  be  more  gratifying  than 
those  upon  the  stomach.  This  form  of  electricity  is  employed  in 
gastric  atony  and  gastralgia,  but  more  often  in  intestinal  neuroses, 
membranous  colitis,  and  atonic  and  spastic  constipation.  It  is 
also  used  in  the  treatment  of  anal  fissure  (see  page  861). 

The  alternating  faradic  (sinusoidal)  current  in  which  the  potential 
rises  gradually  from^zero  to  a  maximum,  and^then  gradually  returns 
to  zero  or  to  a  minimum,  gives  splendid  results. 

Static  electricity  in  the  treatment  of  diseases  of  the  digestive 
organs  is  disappointing. 


CHAPTER  XL 

TREATMENT  OF  DISEASES  OF  THE  INTESTINE 
THROUGH  THE  RECTUM. 

Rectal  therapeutics  plays  an  important  role  in  the  treatment 
of  diseases  of  the  intestine.  This  class  of  therapeutic  procedures 
should  fulfil  one  of  two  indications:  (1)  To  empty  the  bowel  by 
stimulating  peristalsis;  that  is,  to  act  purgatively.  (2)  To  act 
upon  the  intestine  in  such  a  manner  that  inflammatory  processes 
of  the  .diseased  intestinal  mucous  membrane  are  improved  by  direct 
local  treatment,  retarding  peristalsis  and  checking  diarrhea;  in 
other  words,  securing  a  constipating  effect. 

The  first-mentioned  indication  is  attained  by  the  so-called 
cleansing  enemata.  These  are  made  use  of  in  all  acute  and  chronic 
intestinal  stagnations,  both  primary  and  secondary.  Cleansing 
enemata  are  most  extensively  employed  in  chronic  constipation. 
For  this  purpose  they  are  more  valuable  than  purgatives.  When 
it  is  impossible  to  attain  a  satisfactory  result  by  dietetic  means, 
enemata  are  first  to  be  used,  and  only  in  case  of  their  failure  should 
we  resort  to  purgatives. 

CLEANSING  ENEMATA. 

The  technic  of  cleansing  enemata  is  as  follows:  A  soft  rectal 
tube,  made  of  the  same  kind  of  rubber  as  that  used  for  stomach 
tubes,  is  employed.  This  rectal  tube  may  be  closed  at  its  lower  end, 
with  one  or  two  lateral  apertures,  or  it  may  have  one  opening  at  the 
extreme  end  and  one  lateral  opening.  The  edges  of  these  openings 
must  be  smoothed  and  rounded,  in  order  to  guard  against  any 
injury  to  the  mucous  membrane  of  the  rectum.  The  caliber  of  the 
rectal  tube  should  be  as  large  as  possible,  especially  if  it  be  desired 
that  the  outflow  of  the  water  take  place  through  the  same  tube. 
The  lower  half  of  an  ordinary  rubber  stomach  tube  (Fig.  31), 
having  a  closed  point  and  two  lateral  openings,  is  best  adapted 
for  use  as  a  rectal  tube.  This  instrument  rarely  becomes  stopped 
up.  The  end  of  the  tube  should  be  well  oiled  and  introduced  into 
the  rectum  of  the  patient  for  a  distance  of  about  ten  to  fifteen 
centimeters  (3  to  5  inches)  with  careful  pressure.  The  tube  should 
never  be  forced  farther  than  can  be  accomplished  without  a  feeling 
of  resistance.  It  is  usually  easy  to  pass  the  tube  high  up  while 
fluid  is  flowing  into  the  rectum.    Hard  tubes  made  of  wood,  vulcan- 


CLEANSING  EN  EM  ATA  221 

ized  rubber,  or  glass,  as  substitutes  for  the  soft  rubber  reetal  tubes, 
are  to  be  used  with  great  caution,  because  they  may  easily  injure 
the  mucous  membrane  even  when  skilfully  handled.  After  the 
introduction  of  the  soft  rubber  rectal  tube,  the  latter  is  joined  to  a 
piece  of  wide  glass  tubing  and  this  is  connected  with  a  rubber 
tube  which  is  attached  to  an  irrigator  of  glass  having  a  capacity 
of  about  1500  Cc.  (3  pints).  This  apparatus  corresponds  exactly  to 
that  used  in  lavage  of  the  stomach.  The  irrigator  is  graduated, 
and  constructed  in  such  a  manner  that  it  may  be  suspended  from  a 
hook.  The  diameter  of  the  outflow  opening  should  be  as  wide  as 
possible.  The  tube  used  for  making  connection  should  be  of  the 
best  thick  black  rubber.  One  end  of  the  connecting  glass  tubing 
should  be  somewhat  narrower  than  the  other,  that  it  may  be  easily 
introduced  into  the  rectal  tube.  A  large  glass  funnel  may  be  used 
instead  of  the  irrigator,  though  the  latter  has  the  advantage  that  it 
can  be  placed  on  the  floor  and  the  outflow  of  the  water  can  then  be 
easily  watched.  The  pressure  of  the  inflowing  water  can  be  easily 
regulated  by  elevating  or  lowering  the  irrigator  or  funnel.  This  is 
of  great  importance,  especially  in  patients  with  a  very  sensitive 
intestine  and  in  those  suffering  with  tenesmus.    The  employment  of 


Fig.  31. — Rectal  tube,  showing  solid  end  and  elongated  lateral  opening. 

piston  syringes  and  rubber-bulb  syringes  is  not  to  be  recommended; 
they  are  sometimes  connected  with  the  rectal  tube  after  the  latter 
is  introduced.  It  is  only  with  great  difficulty  that  intra-intestinal 
pressure  can  be  regulated  in  the  use  of  these  syringes,  and  over- 
distention  of  the  gut  may  result,  causing  pains  and  tenesmus.  An- 
other practical  drawback  is  the  fact  that  the  syringes  are  not 
capable  of  holding  a  sufficient  quantity  of  water. 

It  is  useless  to  insert  the  rectal  tube  farther  than  the  distance 
mentioned  above  (10  to  15  centimeters).  The  so-called  "high 
colonic  irrigations,"  which  require  the  introduction  of  the  rectal 
tube  high  up,  have  been  found  to  be  practically  impossible.  Roent- 
gen fluoroscopy  shows  that  a  soft  rubber  tube  cannot  be  made 
to  go  any  higher  than  six  or  seven  inches  into  the  rectal  ampulla 
without  bending  or  coiling  on  itself.  Only  in  rare  cases  can  it  be 
made  to  penetrate  into  the  colon.  To  completely  fill  the  colon 
with  liquid  it  is  not  necessary  to  insert  the  tube  very  high.  The 
result  desired  is  accomplished  much  better  by  allowing  the  patient 
to  assume  a  suitable  posture — either  the  left  lateral  or  the  knee- 
chest.  The  intra-abdominal  pressure  is  thus  diminished  and  the 
fluid  is  sucked  up,  as  it  were.     By  this  means  large  quantities  of 


222     INTRARECTAL    TREATMENT  OF  INTESTINAL   DISEASES 

liquid  can  be  made  to  ascend,  under  low  pressure,  through  the  colon 
into  the  cecum.  The  ileocecal  valve  can  rarely  be  passed  by  the 
fluid.  To  completely  fill  the  entire  large  intestine,  six  liters  of 
liquid  are  required. 

With  the  apparatus  mentioned  above,  the  patient  is  enabled 
to  administer  these  enemata  himself.  In  such  an  event  the  rectal 
tube  had  better  be  joined  to  the  irrigator  tube  (Fig.  16)  before 
being  introduced  into  the  rectum.  The  irrigator  being  suspended 
at  a  moderate  height,  and  the  fluid  allowed  to  flow  as  far  as  the 
end  of  the  tube  in  order  to  expel  all  the  air  that  may  be  present, 
the  tube  is  then  shut  off  by  means  of  a  large  tube-clamp.  The  patient 
assumes  the  left  lateral  position,  with  the  pelvis  slightly  elevated. 
The  rectal  tube  is  inserted,  and  the  flow  and  pressure  of  water  are 
regulated  at  will  by  manipulation  of  the  clamp. 

The  quantity  of  water  to  be  introduced  should  not  be  too  large. 
About  300  Cc.  (10  ounces)  of  liquid,  flowing  in  under  low  pressure, 
is  sufficient  for  cases  of  chronic  constipation  in  which  the  patient 
is  obliged  to  resort  to  enemata  in  order  to  "move"  the  bowels. 
Regular  and  long-continued  employment  of  large-sized  enemata, 
one  liter  or  more,  is  actually  harmful,  for  a  marked  atony  and 
overdistention  of  the  rectum  may  result,  causing  a  weakness  of 
the  muscular,  tissues.  The  chief  point  is  that  the  small  enemata, 
of  300  Cc.  (10  ounces),  should  be  retained  as  long  as  possible — 
for  hours,  or  if  possible  during  the  entire  night.  For  this  reason  it 
is  well  to  have  the  injections  made  at  night,  evacuation  taking 
place  the  following  morning.  The  purgative  effect  of  these  enemata 
is  brought  about  in  the  following  manner:  The  peristalsis  is 
mechanically  stimulated  by  the  inflowing  water,  the  slight  dis- 
tention of  the  intestinal  wall,  and  the  irritation  from  the  tube  in 
the  rectum.  The  degree  of  increase  in  the  peristalsis  is  dependent 
on  the  temperature  of  the  liquid;  cold  irrigations  (65°  to  70°  F.) 
act  more  powerfully  than  warmer  ones.  Then  there  is  the  soften- 
ing effect  of  the  water  on  the  firm  fecal  mass  to  be  taken  into  con- 
sideration. This  effect  is  only  obtainable  when  the  enema  is  retained 
for  a  long  time.  Ordinary  water  of  different  temperatures  is  fre- 
quently efficacious,  but  it  is  sometimes  advisable  to  add  to  the 
water  various  substances,  such  as  chamomile  tea,  soap,  oil,  glycerin, 
sugar,  honey,  vinegar,  soda,  common  salt,  molasses,  castor  oil, 
or  oil  of  turpentine.  Soap  has  the  most  energetic  action  in  dis- 
solving fecal  matter,  and  oil  stands  next.  Lime-water  has  also 
been  recommended. 

Glycerin  Enemata. — Small  glycerin  enemata  (about  5  to  15  Cc), 
slowly  injected  into  the  rectum,  by  abstracting  water  from  the 
tissues  reflexly  stimulate  peristalsis  and  frequently  cause  evacua- 
tion within  a  few  minutes.  This  peristaltic  stimulation  extends 
over  the  lowest  portion  of  the  gut  only;  the  use  of  glycerin  is 
rational  and  effective,  therefore,  only  for  emptying  the  rectum. 


OIL  EN  EM  AT  A  _'_'.; 

Glycerin  in  suppository  form  acts  in  the  same  manner.  In  nervous 
patients  the  use  of  glycerin  occasionally  gives  rise  to  nausea  and 
vomiting. 

Oil  Enemata. — Fleiner's  oil  enemata  are  extensively  used  in 
the  treatment  of  chronic  atonic  and  spastic  constipation.  Fleiner 
recommends  for  this  class  of  cases  one  injection  daily  of  250  to 
500  Cc.  (|  to  1  pint)  of  the  purest  olive  or  sesame  oil.  The  oil 
is  to  be  retained  in  the  bowel  for  a  considerable  time;  it  is  best 
to  retain  it  overnight  if  possible.  Should  discomfort  during  the 
night  (meteorism,  pressure)  result,  as  may  occasionally  happen, 
the  time  of  administration  should  be  changed,  the  enema  being 
given  at  six  or  seven  o'clock  in  the  morning  while  the  patient  is  in 
bed;  the  oil  is  then  to  be  retained  for  three  or  four  hours,  thus 
producing  the  same  laxative  effect  as  if  it  had  been  administered 
at  night. 

These  injections  should  be  continued  for  several  months,  at 
first  daily,  later  every  other  day,  and  subsequently  twice  a  week. 
The  results  are  so  good  that  in  many  cases  of  chronic  constipation 
actual  recovery  is  brought  about  without  any  other  treatment.  The 
oil,  by  partially  breaking  up  into  fatty  acids,  stimulates  peristalsis. 
When  there  is  spastic  constipation  the  oil  has  a  soothing  effect  on 
the  tense  muscular  tissue;  and  in  atonic  constipation  it  strengthens 
the  muscular  tonus.  Besides  it  lubricates  the  gut,  softens  the  fecal 
agglomerations,  and  forms  a  protective  layer  upon  the  inflamed 
portions  of  the  mucous  membrane  (see  page  671). 

As  a  rule  no  discomfort  is  caused  by  the  "oil  cure,"  and  the 
patients  are  at  the  time  hardly  aware  of  the  fact  that  the  oil  is 
being  introduced.  It  has  not  been  ascertained  definitely  whether 
the  oil  passes  beyond  the  ileocecal  valve  in  all  cases,  but  some 
patients  experience  the  taste  of  oil  after  receiving  a  number  of 
enemata.  The  only  inconvenience  caused  by  the  oil  enemata  is 
the  impossibility  of  avoiding  the  soiling  of  the  bed  and  the  bed- 
clothes. The  patient  must  remain  in  bed  for  at  least  an  hour  after 
the  injection,  without  indulging  in  much  conversation,  coughing  or 
laughing.  Should  there  be  no  spontaneous  action  of  the  bowels  in 
the  morning,  a  small  lukewarm  sodium-chlorid  water  enema  should 
be  given. 

The  oil  may  be  made  to  flow  through  the  apparatus  previously 
described,  the  irrigator  being  held  high.  Because  of  the  viscosity 
of  the  oil,  the  pressure  may  have  to  be  somewhat  stronger  than 
usual.  A  piston  syringe  of  glass,  hard  rubber,  or  metal,  holding 
300  Cc.  (10  ounces),  may  be  used;  the  nozzle  is  to  be  attached  to 
a  soft  rubber  rectal  tube.  The  syringe  should  be  elevated  during 
the  injection,  and  considerable  pressure  may  be  made  upon  it. 
Zweig  (Fig.  32)  has  constructed  an  oil  enemator  after  the  manner  of 
a  squirting  bottle.  The  oil  is  placed  in  an  Erlenmeyer  flask  (a) 
which  is  closed  by  a  doubly  perforated  rubber  stopper  (6).    Through 


224    INTRARECTAL   TREATMENT   OF  INTESTINAL   DISEASES 

one  of  the  openings  in  the  stopper  a  glass  tube  (c)  passes  to  the 
bottom  of  the.flask;  the  outer  extremity  is  then  joined  to  the  rectal 
tube  (/)  by  a  piece  of  rubber  tubing  (d)  with  glass  connection  (e). 
Through  the  other  opening  in  the  rubber  stopper  a  short  tube  is 
inserted,  care  being  taken  that  it  does  not  touch  the  level  of  the 
oil.  As  in  the  squirting  bottle,  air  is  forced  into  the  flask  by  means 
of  a  double  rubber -bulb  apparatus  (</)  under  gentle  but  uniform 
pressure. 


Fig.  32. — Oil  enemator.  (Zweig.)  a,  Erlenmeyer  flask ;  6,  doubly  perforated 
rubber  stopper;  c,  glass  tube;  d,  rubber  tube;  e,  glass  connection;  /,  rectal  tube;  g, 
double  rubber  bulb. 


An  apparatus  for  the  injection  of  oil  devised  by  Dudley  D. 
Roberts  consists  of  a  curved  rectal  tube  of  hard  rubber,  ending  in  an 
olive-shaped  nozzle,  and  attached,  by  means  of  a,  soft  rubber  tube 
of  convenient  length,  to  a  ten-ounce  Politzer  bag  (Fig.  33).  The 
rectal  tube  is  made  with  such  a  curve  that  it  is  readily  passed  from 
the  front  of  the  body  to  the  anal  opening;  here  by  a  slight  traction 
movement  it  enters  the  anus  in  the  proper  direction,  pointing  toward 


PARAFFIN  ENEMATA 


225 


the  umbilicus.  This  new  form  of  tube  is  much  less  awkwardly 
introduced  than  by  reaching  around  behind  the  buttocks.  The 
Politzer  bag  is  fitted  with  a  stopcock  having  a  small  hole  in  one 
side,  which  permits  the  bag  to  fill  with  air  when  the  cock  is  closed. 
The  method  of  taking  the  injection  is  simple:  The  bag  is  allowed 
to  fill  itself,  and  the  oil  is  then  warmed  by  placing  the  bag  in  warm 
water.  The  patient  lies  on  his  back,  with  hips  somewhat  elevated, 
and  introduces  the  rectal  tube  with  the  soft  rubber  tubing  attached. 
The  bag  is  then  attached,  the  stopcock  turned,  and  the  oil  slowly 


Fig.  33. — Oil  enemator.     (Roberts.) 


forced  into  the  rectum.  The  bag,  being  emptied,  is  closed  by 
reversing  the  stopcock;  dilated  by  the  air  which  thus  gains 
entrance;  and  compressed  again  to  force  out  what  oil  remains  in 
the  tubing.  By  shutting  off  the  stopcock  we  prevent  the  return 
of  any  oil  into  the  tube  and  obviate  the  danger  of  soiling  clothing 
and  bedding. 

Paraffin  Enemata.- — Lipowski  has  quite  recently  advocated  the 

paraffin  mixture  instead  of  oil.     The  hardness  of  the  stools  in 

chronic  constipation  being,  as  he  says,  due  to  the  fact  that  much 

more  water  is  absorbed  by  the  mucous  membrane  of  the  sigmoid 

15 


226     INTRARECTAL    TREATMENT   OF  INTESTINAL   DISEASES 

flexure  and  the  rectum  than  in  health,  it  is  desirable  to  prevent 
this  loss  of  water  if  possible.  This  he  attempts  to  do  by  the 
introduction  of  agents  into  the  rectum  which  retard  absorption, 
Paraffin,  according  to  Lipowski,  has  this  effect.  He  makes  use  of 
a  preparation  that  has  a  melting  point  of  about  100°  F.,  consisting 
of  solid  paraffin  (melting  point  160°  F.)  and  liquid  petrolatum  in 
the  proportion  of  one  of  the  former  to  eight  of  the  latter.  The 
mixture  is  heated,  either  in  a  water-bath  or  over  a  flame,  until  it 
becomes  all  liquid.  Of  this,  200  Cc.  (7  ounces)  is  slowly  injected 
through  a  soft  rubber  rectal  tube.  Several  advantages  are  claimed 
for  the  paraffin  injections,  among  others  that  they  do  not  necessitate 
lying  down  for  hours  after  the  injection  as  oil  enemata  do,  and  the 
paraffin  mass  spreads  over  the  surface  of  the  mucous  membrane  in 
the  manner  of  an  ointment  very  soon  after  the  injection.  The 
paraffin  is  absolutely  non-irritating  and  it  does  not  decompose,  as 
ordinary  oils  do.  In  the  paraffin  treatment  large  volumes  of  flatus 
are  not  formed,  as  may  happen  in  the  oil  treatment,  and  the  clothing 
and  bedding  are  not  soiled  by  malodorous  masses.  The  purgative 
effect  of  paraffin  is  said  to  be  much  more  prompt  than  that  of  oil. 
Paraffin  is  very  well  adapted  for  continued  use,  because  of  its 
absolutely  non-irritating  character.  The  patients  are  able  to  apply 
the  injections  themselves.  Lipowski  has  reported  permanenty  good 
results  from  this  method  of  treatment. 

Carbon  Dioxid. — Adolf  Schmidt,  taking  into  consideration  the 
fact  that  gases  are  a  physiologic  stimulant  to  peristaltic  movement, 
has  proposed  to  employ  as  enemata  liquids  containing  carbon 
dioxid,  such  as  selters  water  and  carbonated  oil  of  sesame.  These 
enemata  may  be  introduced  by  allowing  the  fluids  to  pass  directly 
into  the  rectum  from  the  bottle — a  rectal  tube  attached  to  a  rubber 
tube  being  connected  with  the  neck  of  the  bottle.  By  turning, 
shaking  and  inverting  the  bottle,  carbon  dioxid  is  developed  in 
large  volume,  forcing  the  contents  of  the  bottle  into  the  rectum. 
The  ordinary  selters  water  bottle  as  found  in  the  shops  can  be 
used;  a  rectal  tube  can  be  easily  attached  to  the  faucet  (Fig.  34). 
These  enemata  should  be  retained  as  long  as  possible,  although  it 
is  not  feasible  to  hold  them  as  long  as  the  non-gaseous  fluids. 
The  carbon  dioxid  has  a  refreshing  influence  on  the  mucous  mem- 
brane of  the  intestine  and  stimulates  both  tonus  and  peristalsis. 

Bile  Enemata. — Bensaude  reports  good  results  in  the  treatment  of 
constipation  by  means  of  bile  enemata.  Of  interest  is  the  fact  that 
this  is  one  of  the  oldest  measures  known  in  medicine,  for  1300  years 
before  Christ  a  mixture  of  beef  bile  and  milk,  in  the  proportion  of 
one-third  bile  and  two-thirds  milk,  was  used  as  an  enema  for  con- 
stipation by  the  Egyptians.  Bile  is  capable  of  exciting  contraction 
of  the  colon  as  well  as  of  the  small  intestine.  A  single  dose  of  10  Gm. 
(2|  drachms)  of  bile  causes  colicky  contractions.  The  dry  extract 
dissolves  freely  in  water.    A  half-liter  (1  pint)  of  the  solution  is 


CATHARTICS 


227 


allowed  to  enter  the  rectum  by  gravity;  and  in  five  to  ten  minutes 
an  evacuation  of  the  bowel  occurs. 

Cathartics. — Attempts  have  also  been  made  to  secure  a  purgative 
effect  by  the  introduction  of  small  enemata  containing  cathartics. 
The  active  principles  of  various  purgatives  have  been  tried — aloin, 
colocynthin,  cathartin,  and  citrullin.  This  method,  however,  is  as 
yet  only  in  the  experimental  stage. 

All  the  above-mentioned  measures  refer  principally  to  the  over- 
coming of  chronic  constipation.  The  administration  of  water 
enemata  with  or  without  some  adjuvant  must  also  be  considered  in 
the  treatment  of  acute  constipation;  in  acute  and  very  persistent 
constipation  with  organic  cause,  as  much  as  1|  liters  (3  pints)  may 
be  introduced,  to  be  retained  for  a  short  time  only,  and  the  injection 
repeated  if  necessary. 


Fig.  34. — Carbon  dioxid  bottle  with  soft  rubber  rectal  tube  attached,     a,  siphon 
bottle;  b,  rubber  tube;  c,  glass  connection;  d,  soft  rubber  catheter. 

In  stenosis  of  the  large  intestine  the  cause  of  the  constipation 
is  usually  the  accumulation  of  coarse  remnants  of  food  above 
the  stricture.  By  administering  small  or  large  enemata,  rapidly 
repeated  by  alternately  elevating  and  lowering  the  irrigator,  the 
obstruction  may  in  many  cases  be  removed.  When  the  occlusion 
is  caused  by  gallstones,  fecal  concrements,  or  swallowed  foreign 
substances,  it  is  often  possible  to  soften  and  remove  the  obstruc- 
tive masses  by  frequent  and  dextrous  rectal  irrigations.  Boas 
warmly  recommends  chloroform-water  irrigations  (10  :  200)  in  cases 
of  gallstone  ileus  for  the  purpose  of  partially  dissolving  the  concre- 


228     INTRARECTAL    TREATMENT  OF   INTESTINAL   DISEASES 

merits.  These  irrigations,  with  large  quantities  of  fluid,  sometimes 
require  general  anesthesia,  particularly  when  it  is  desired  to  over- 
come the  resistance  at  the  ileocecal  valve. 

To  relieve  intussusceptions,  rectal  irrigations  are  very  serviceable. 
Nothnagel  used  5  to  8  per  cent,  sodium  chlorid  solutions  in  these 
particular  cases.  To  remove  the  gases  found  in  meteorism,  large 
enemata  are  likewise  to  be  employed  and  rapidly  evacuated;  the 
water  returning  under  pressure  is  capable  of  carrying  away  with 
it  large  quantities  of  gas.  It  may  be  mentioned  that  Curschmann 
recommended  the  insufflation  of  air  into  the  rectum  in  cases  of 
constipation  due  to  stenosis  caused  by  tumor  or  intussusception. 
This  procedure,  however,  is  not  without  danger,  because  of  the 
liability  of  tearing  or  causing  perforation,  particularly  in  ulcerative 
and  gangrenous  processes.  The  insufflation  of  air  is  accomplished  by 
means  of  a  double  rubber-bulb  apparatus  attached  to  a  rectal  tube. 

Intestinal  Douche. — The  intestinal  douche  is  employed  to  stimu- 
late peristalsis  and  to  strengthen  the  muscles  of  the  lower  section 
of  the  bowel.  The  douche  is  applied  with  a  rectal  tube  similar 
to  Rosenheim's  gastric  douche,  which  is  provided  with  numerous 
small  openings  at  its  lower  end  through  which  the  fluid  is  expelled  in 
jets  (Fig.  35).    The  liquids  used  are  either  cold  water,  or  hot  and 


Fig.  35. — Perforated  tube  for  rectal  douche. 

cold  water  alternately,  or  water  containing  carbon  dioxid.  The 
rectum  should  be  empty  at  the  time;  a  cleansing  enema  will  empty 
it  before  using  the  douche. 

MECHANICAL  TREATMENT. 

Swedish  Manipulation. — Certain  manual  methods,  apart  from 
the  use  of  enemata,  are  at  our  disposal  for  bringing  about  evacua- 
tion of  the  bowel.  Akerhielm  recently  recommended  Swedish 
manipulation  in  cases  of  very  obstinate  chronic  constipation. 
The  patient  is  placed  on  his  left  side  upon  a  low  couch,  with  the 
knees  well  flexed.  The  attending  physician  stands  behind,  and 
exerts  a  light  counterpressure  with  the  left  hand  on  the  patient's 
upper  hip;  his  right  index  finger,  covered  with  a  well-oiled  rubber 
glove  or  a  thin  finger  cot,  is  then  inserted  into  the  rectum.  The 
palm  of  the  hand  is  turned  outward,  away  from  the  genital  region 
of  the  patient,  and  the  finger  is  slightly  bent;  both  anal  sphincters 
are  then  carefully  passed  until  the  ampulla  is  reached.  Normally 
the  mass  of  fecal'  matter  pressing  downward  during  defecation 
mechanicallv  stimulates  the  walls  of  the  rectum,  and  this  stimulus, 


RECTAL  MASSAGE  229 

transmitted  by  fibers  from  the  hemorrhoidal  plexus  to  the  ano- 
spinal  center,  reflexly  induces  evacuation.  Akerhielm  endeavors 
to  imitate  or  replace  this  impetus,  which  is  absent  in  chronic  con- 
stipation, by  executing  frictional  movements  with  the  inserted 
finger  along  the  walls  of  the  rectum.  All  parts  belonging  to  the 
genital  apparatus  are  most  carefully  avoided.  The  manipulation 
should  be  directed  toward  the  lateral  soft  parts  of  the  ampulla, 
where  the  hemorrhoidal  plexus  is  embedded.  The  stimulation 
must  not  be  applied  with  too  much  vigor,  although  the  sensitiveness 
in  the  interior  of  the  rectum  is  not  very  pronounced;  it  must 
always  be  borne  in  mind  that  these  tissues  are  very  tender  and 
markedly  vascular.  The  stimulations  are  to  be  made  slowly,  and 
the  whole  procedure  should  not  continue  longer  than  two  or  three 
minutes.  Akerhielm  does  not  give  any  purgatives  or  enemata. 
He  succeeds  in  effecting  a  bowel  movement  in  his  patients,  even 
a  copious  one,  by  means  of  a  single  treatment.  The  feces  become 
moist,  the  mucous  membrane  lubricated,  and  an  evacuation  takes 
place  within  ten  hours  after  the  manipulation.  The  cure  is  said 
to  take  from  four  to  six  weeks,  the  manipulation  being  done  once 
daily.  In  the  course  of  six  months  to  a  year  a  short  after-cure  series 
of  manipulations  should  be  undertaken. 


a 


Fig.  36. — Apparatus  for  rectal  massage,     a,  inflated;  b,  deflated. 

Rectal  Massage. — Hirschman  has  devised  a  method  of  rectal 
massage  with  a  pneumatic  dilator  mounted  on  a  bougie,  which  is 
quite  simple.  The  instrument  consists  of  an  ordinary  Wales 
bougie,  supplied  with  an  inflating  bulb,  and  covered  at  its  distal 
end  with  a  thin  rubber  bag  (Fig.  36).  The  rubber  bag,  well  lubri- 
cated, is  inserted  into  the  rectum  with  the  patient  in  the  Sims 
position.  It  is  passed  inward,  backward,  and  upward,  following 
the  sacral  curve  to  the  entrance  into  the  sigmoid;  it  is  then  slowly 
inflated  for  about  ten  to  fifteen  seconds.  The  bag  should  be  allowed 
to  empty  as  soon  as  its  distention  causes  a  feeling  of  fulness  or 
cramp.  This  inflation  and  deflation,  four  to  six  times  a  minute, 
should  be  kept  up  for  five  to  ten  minutes;  then  the  bag  is  inflated 
to  the  point  of  tolerance,  the  openings  in  the  bougie  stopped  with 
the  thumb  and  forefinger,  and  the  apparatus  withdrawn  with  a  to- 
and-fro  movement,  thus  massaging  the  sphincter  and  rectum  in  its 
exit.    With  instructions  to  the  patient  regarding  regular  hours  for 


230     INTRARECTAL   TREATMENT  OF  INTESTINAL   DISEASES 

defecation,  the  proper  diet  and  exercise,  and  rectal  massage  per- 
sisted in  until  a  daily  stool  is  produced,  Hirschman  has  found  the 
treatment  successful  in  a  vast  majority  of. his  cases.  He  has  had 
less  than  5  per  cent,  of  failures. 

Rectal  Tampons. — MacMillan  has  used  rectal  tampons  in  a 
large  number  of  cases  of  chronic  constipation  with  most  gratifying 
results.  A  tampon  placed  above  the  rectal  valves,  and  allowed 
to  remain  for  three  or  four  hours,  will  usually  ensure  a  bowel  move- 
ment within  twenty-four  hours,  and  in  most  instances  another 
movement  before  the  expiration  of  another  twenty-four  hours. 
The  tampons  are  composed  of  cotton,  lamb's  wool,  or  gauze.  They 
are  easily  inserted  through  a  proctoscope  (Fig.  37),  and  cause  the 
patient  no  pain  or  inconvenience;  he  may  leave  the  office  with 
directions  to  withdraw  the  tampon  in  three  or  four  hours.  In  the 
majority  of  cases  a  tampon  every  second  day  for  two  weeks  is 
sufficient  to  effect  a  cure.  The  tampon  is  solid  and  resembles 
sufficiently  in  consistency  the  normal  feces  in  the  rectum  or  sigmoid. 
It  does  not  cause  any  chemical  irritation.  Any  desired  degree  of 
distention  may  be  obtained  by  increasing  the  size  of  the  tampon. 
The  tampon  may  be  retained  for  a  considerable  length  of  time;  and 
to  this  close  resemblance  to  the  natural  stimuli  MacMillan  believes 
much  of  its  therapeutic  value  is  due. 


Fig.  37. — Kelly's  proctoscope. 

Rectal  Electrodes.— The  electric  current  applied  in  the  rectum  is 
capable  of  stimulating  peristalsis.  The  apparatus  used  for  this 
purpose  is  identical  in  construction  with  the  electric  stomach  tube 
of  Boas  (Fig.  38),  and  admits  of  both  inflow  and  outflow  of  water. 
The  electrode  being  introduced  into  the  rectum,  100  to  200  Cc. 
(3  to  7  ounces)  of  lukewarm  sodium-chlorid  solution  is  injected 
before  turning  on  the  current.  The  other  electrode,  consisting  of 
a  broad  plate  or  a  roller,  is  placed  upon  the  abdomen  and  moved 
along  in  the  direction  of  the  large  intestine.  Either  the  faradic 
or  the  galvanic  current  may  be  used.  The  faradic  current  may  be 
made  strong  enough  to  produce  distinct  muscular  contractions. 


RECTAL  ELECTRODES 


l>:;i 


The  patient  should  not  experience  inure  than  a  distinct,   slightly 
painful  prickling  sensation.    With  the  galvanic  current,  twenty  to 


mn 


Fig.  38. — Rectal  electrode.     (Boas.) 

thirty  milliamperes  are  sufficient.  After  the  treatment  has  been 
concluded,  the  water  is  allowed  to  flow  out  directly  through  the 
electrode.    Generally  speaking,  electricity  should  be   applied  intra- 


Fig.  39. — Rectal  electrode.     (Zweig.) 

rectally  only  in  cases  in  which  the  other  methods  of  treatment  do 
not  accomplish  the  purpose.  The  sinusoidal  current  is  the  one 
generally  used. 


Fig.  40. — Curved  rectal  electrode. 


Zweig  also  has  constructed  a  rectal  electrode  (Fig.  39),  with  a 
metal  screw  head,  which  allows  the  inflow  and  outflow  of  water. 

Figs.  40  and  41  show  two  simple  electrodes  with  metal  buttons, 
without  provision  for  the  inflow  of  water.     The  faradic  current 


232     INTRARECTAL    TREATMENT   OF  INTESTINAL   DISEASES 

only  should  be  used  "with  this  form  of  electrode,  as  the  mucous 
membrane  might  be  cauterized  from  the  galvanic  current. 


Fig.  41. — Straight  rectal  electrode. 

An  enema  of  water  to  cleanse  the  rectum  is  not  absolutely 
necessary  before  faradization.  The  proper  duration  of  intrarectal 
faradization  is  five  to  ten  minutes.  The  current  is  at  first  applied 
very  weak,  then  increased,  and  finally  very  gradually  and  slowly 
decreased.  Usually  the  galvanic  current  is  employed  in  irritable 
conditions  of  the  gut,  the  faradic  or  sinusoidal  current  being  reserved 
for  relaxed  conditions. 

TREATMENT  OF  INTESTINAL  IRRITATION. 

Irrigation  of  the  Intestine.- — Irrigation  of  the  intestine  is  the  best 
procedure  for  fulfilling  the  second  indication  in  rectal  intestinal 
treatment;  it  effects  a  cure  of  the  morbid  processes  by  direct 
action  on  the  intestinal  mucous  membrane,  thus  arresting  the 
diarrhea.  The  purpose  of  irrigation  is  to  remove  noxious  material, 
such  as  blood,  mucus,  pus,  putrefying  and  fermenting  material,  to 
neutralize  the  harniful  effects  of  these  substances  on  the  intestinal 
mucous  membrane,  and  to  produce  a  direct  therapeutic  effect. 

Intestinal  irrigations  for  the  removal  of  noxious  materials  are  per- 
formed with  the  apparatus  mentioned  on  page  199  (Fig.  16).  The 
patient  places  himself  in  the  left  lateral  position,  and  the  irrigating 
fluid  is  allowed  to  enter  the  rectum  under  any  desired  pressure, 
regulated  by  elevation  or  lowering  of  the  irrigator.  The  liquid  is 
allowed  to  escape  immediately,  or  after  it  has  been  retained  for  some 
time.  When  it  is  desired  to  irrigate  the  entire  large  intestine, 
greater  quantities  of  irrigating  fluid,  1  to  1|  liters  (2  to  3  pints),  are 
required,  which  should  be  allowed  to  flow  in  very  slowly  while  the 
pelvis  is  somewhat  elevated.  By  placing  the  irrigator  on  the  floor 
the  return  of  the  greater  part  of  the  fluid  is  effected,  just  as  in  the 
case  of  gastric  lavage,  and  the  quantity  and  quality  of  the  masses 
removed  can  be  satisfactorily  observed  in  the  irrigator  (which  is 
of  glass).  These  irrigations  may  be  frequently  repeated,  always 
with  gentle  pressure  to  avoid  overstretching  the  intestine.  Rectal 
tubes  and  joint  pieces  of  rather  large  caliber  should  be  used  in 
order  to  avoid  obstruction  by  the  fecal  masses.  At  times,  before 
allowing  the  fluid  to  escape,  the  rectal  tube  may  be  entirely  removed 
and  the  liquid  evacuated  directly  into  a  bed-pan.  It  is  obvious 
that  these  irrigations  must  be  made  most  carefully  to  avoid  exces- 


MRIUATIO.W  OF  THE  INTESTIXE 


233 


sive  pressure;  the  sensations  of  the  patient  as  regards  pain  or 
tenesmus  afford  it  reliable  guide.  Should  the  disease  be  situated  in 
the  descending  colon,  in  the  sigmoid  flexure,  or  in  the  rectum,  the 
amount  of  fluid  used  need  not  be  large. 

The  apparatus  mentioned  on  page  199  (Fig.  16)  is  sufficient  for  all 
purposes  of  irrigation.  Zweig  has  constructed  a  special  irrigating 
tube  (Fig.  42),  consisting  of  a  strong  piece  of  glass  tubing  rounded 
at  the  end  and  with  two  oval  openings  two  or  three  centimeters 
from  the  end,  one  on  each  side.  The  lumen  of  the  glass  tube  is 
divided   longitudinally  by  a  diaphragm  into  two  non-communicat- 


Fig.  42. — Irrigation  tube.  (Zweig.)  a,  small  opening  in  glass  tube  leading  to 
funnel;  b,  opening  through  which  water  flows  out  of  rectum;  c,  diaphragm  dividing 
glass  tube  into  two  halves. 

ing  halves.  One  of  these  halves  is  connected  with  a  rubber  tube 
attached  to  a  funnel,  and  serves  for  the  inlet  of  the  water,  while 
the  other  half  is  attached  to  a  shorter  rubber  tube  leading  the 
outflowing  water  into  a  vessel.  The  irrigation  is  made  in  the 
following  manner:  The  well  oiled  glass  tube  is  inserted  into  the 
anus  of  the  patient,  who  is  lying  on  his  left  side.  Water  being 
allowed  to  flow  from  the  irrigator,  the  air  present  in  the  apparatus 
escapes  with  a  noise  through  a  into  the  rectum  and  from  there 
through  b  into  the  outflow  tube.  Now  follows  the  irrigating  water, 
which  washes  and  rinses  the  rectum  and  leaves  it  by  b.  Water  is 
continuously  or  at  short  intervals  poured  into  the  elevated  funnel 


234    INTRARECTAL   TREATMENT  OF  INTESTINAL   DISEASES 

or  irrigator  until  the  rectum  has  been  thoroughly  washed.  When 
it  is  desired  to  irrigate  higher  up,  the  outflow  rubber  tube  is  clamped 
off;  the  water  is  then  unable  to  escape  so  rapidly  and  must  first 
pass  into  the  higher  sections  of  the  intestine. 

Rosenberg  recently  constructed  an  irrigation  apparatus  which 
is  all  metal  (Fig.  43).  It  is  somewhat  longer  than  the  normal 
rectum.  When  inserted,  its  upper  cupola  lies  in  the  inferior  end 
of  the  sigmoid  flexure  and  thus  prevents  the  irrigating  fluid  from 
passing  higher  up.  In  the  axis  of  the  apparatus  is  situated  an 
irrigation  tube  provided  with  numerous  apertures  (b)  through 
which  the  fluid  enters  the  rectum.  The  fluid  escapes  by  the  out- 
flow tube  (c).  This  irrigation  tube  (b)  is  easily  removable  from  the 
apparatus  and  may  be  replaced  by  the  tube  d  with  which  direct 
application  of  medicinal  substances  can  be  made. 


Fig.  43. — Irrigation  apparatus.    (Rosenberg.)    a,  outside  metal  covering;  b,  irrigating 
tube  with  apertures;  c,  outflow  tube;  d,  for  direct  application  of  medicaments. 


Wolbarst  has  devised  an  improved  rectal  irrigation  tube  of  great 
value  (Figs.  44  and  45).  The  tip  of  the  instrument  is  of  soft,  pliable 
rubber,  which  bends  easily  on  contact  with  the  rectal  wall,  and  the 
flow  of  liquid  into  the  rectum  is  through  numerous  small  openings, 
thus  providing  a  fountain  spray  instead  of  a  single  or  double  jet. 
There  are  two  tubes,  one  inside  the  other.  The  water  enters  through 
the  small  tube  (a)  and  fills  up  the  soft  rubber  pouch  (b),  through 
which  it  enters  the  rectum.  Escape  from  the  rectum  is  only  possible 
through  a  large  opening  (d)  in  the  larger  tube  (c).  The  external 
sphincter  (at  /)  prevents  any  outflow  at  the  anus. 

The   instrument  is  made  of  brass  tubing,  nickel  plated,  with  a 


ANTISEPTICS  23:) 

soft  rubber  tip;  the  total  length  is  seven  inches,  including  the  tip. 
The  diameter  is  equivalent  to  38  of  the  French  scale.  The  soft 
rubber  tip  projects  If  inches  beyond  the  end  of  the  large  tube; 
it  is  slipped  over  the  bulbous  end  of  a  short  metal  tube  or  ring,  the 


Fig.  44. — Rectal  irrigation  tube.     (Wolbarst.) 

other  end  of  which  is  provided  with  a  male  thread  which  screws 
into  the  end  of  the  large  tube  (c),  and  is  thus  securely  wedged 
in  place.  It  is  easy,  therefore,  to  unscrew  the  rubber  tip  and 
thoroughly  clean  it  and  the  metal  tubes  at  will. 


/ 


N 

Fig.  45. — Rectal  irrigation  tube,  sectional  view.     (Wolbarst.) 

Antiseptics. — Warm  water,  normal  saline,  or  weak  filtered  chamo- 
mile tea  is  used  for  irrigation.  After  the  gut  has  been  cleansed, 
antiseptic  or  mucus-solvent  substances  may  be  used  for  irrigation, 
to  act  directly  upon  the  mucous  membrane.  The  antiseptic  drugs 
are  boric  acid  (one  teaspoonful  to  a  liter  of  water),  salicylic  acid 
(1 :  1000),  salicylate  of  sodium  (1 :  1000),  weak  solutions  of  per- 
manganate of  potassium  (1 :  10,000),  lysol  (1^  :  1000),  thymol  (one 
teaspoonful  of  a  1-per-cent.  alcoholic  solution  to  one  liter  of  water), 
ichthyol,  benzoate  of  sodium,  naphthol  (1:1000),  quinine  hydro- 
chlorid  (1 :  1000),  and  occasionally  iodoform  emulsion.  For  dissolv- 
ing mucus  we  may  use  the  thermal  waters  of  Carlsbad,  or  Carlsbad 
salt  in  solution,  in  quantities  of  about  200  Cc.  (7  ounces).  Lime- 
water,  and  weak  solutions  of  sodium  carbonate,  sodium  acetate 
or  boric  acid,  are  mucus-solvents.  Application  of  these  solutions 
should  be  frequently  made,  always  just  after  the  bowel  has  been 
cleansed.  Each  treatment  should  be  continued  for  five  to  ten 
minutes.  Such  cleansing  and  disinfecting  irrigations  are  applicable 
in  cases  of  chronic  colitis,  especially  when  associated  with  ulcera- 
tions, and  in  stenosis,  ulcers,  and  ulcerating  tumors  associated  with 
profuse  secretion  of  pus,  blood,  and  serum.  In  the  latter  case 
only  small  quantities  are  to  be  employed  at  one  time,  and  then 
very  carefully. 


236     INTRARECTAL    TREATMENT  OF  INTESTINAL    DISEASES 

Sedatives. — Sedative  irrigations  may  be  employed  when  there  is 
much  irritation,  pain,  and  tenesmus — which  condition  is  found  in 
dysentery  and  other  serious  inflammatory  processes  in  the  large 
intestine  and  the  rectum.  Here,  as  a  rule,  the  basis  of  the  irrigation 
is  a  weak  decoction  of  starch,  a  thin  mucilage  of  gum  arabic,  or  a 
decoction  of  chamomile  tea  or  peppermint,  to  which  is  added  0.5 
to  2  Cc.  (10  to  30  drops)  of  tincture  of  opium,  0.02  to  0.05  Gm. 
(i  to  1  grain)  extract  of  belladonna,  or  2  to  4  Gm.  (30  to  60  grains) 
of  chloral  hydrate.  These  enemata  are  to  be  retained  for  a  con- 
siderable time.  Opium  and  extract  of  belladonna  act  quite  well  in 
such  cases  when  applied  in  the  form  of  suppositories. 

Astringents. — Astringents  may  also  be  applied  to  the  intestinal 
mucous  membrane  by  way  of  the  rectum,  astringent  medicaments 
being  added  to  the  irrigating  fluids.  Silver  nitrate  was  formerly  used 
extensively  (1 :500  to  1 :  1000),  but  has  been  very  properly  abandoned 
because  of  the  excessive  irritation  that  so  frequently  followed  its  use. 
Tannic  acid  (one  teaspoonful  to  a  pint  of  water)  has  been  used  more 
extensively,  but  it,  too,  may  prove  very  irritating,  and  is  not  now 
used  so  often  as  formerly.  Aluminum  acetotartrate  (one  teaspoon- 
ful to  the  pint  of  water)  seems  to  be  less  irritating.  Some  insoluble 
astringents  are  much  milder,  e.  g.,  bismuth  subnitrate  and  bis- 
muth subgallate.  Suspensions  of  these  drugs  are  quite  effective, 
especially  when  made  with  starch  or  gum  arabic.  If  they  are 
allowed  to  remain  for  some  minutes  in  the  intestine,  the  patient 
being  appropriately  placed,  a  portion  at  least  of  the  drug  is  precipi- 
tated on  the  mucosa  and  thus  enabled  to  exert  its  curative  action. 
Such  injections  are  particularly  adapted  to  the  treatment  of  ulcera- 
tive and  severe  catarrhal  processes. 

The  best  results  in  all  catarrhal  conditions  of  the  mucous  mem- 
brane of  the  rectum,  sigmoid  or  colon  are  obtained  by  the  use  of 
krameria.  The  solutions  as  ordinarily  found  in  the  shops  are  useless. 
The  preparation  which  is  recommended  by  Tuttle  and  which  I  have 
found  extremely  valuable  is  prepared  as  follows: 

"Macerate  one  pound  of  bark  of  krameria  in  a  long  percolating 
tube  for  twenty-four  hours.  After  this  a  mixture  of  20  per  cent, 
glycerin  and  80  per  cent,  water  is  allowed  to  percolate  through  it. 
The  percolate  should  be  constantly  stirred,  and  filtered  through  the 
bark  a  second  time.  The  filtrate  is  then  evaporated  down  to  one 
pound,  thus  obtaining  an  aqueous  fluid  extract  containing  minim 
for  grain  all  the  therapeutic  properties  of  the  bark.  The  prepara- 
tion should  be  kept  in  a  dark  place  and  not  exposed  to  the  air." 

This  aqueous  solution  of  krameria  mixes  freely  with  water  and 
can  be  diluted  for  irrigation  to  a  strength  of  from  2  to  20  per  cent. 
For  local  applications  it  can  be  applied  full  strength.  It  has  an 
astringent  and  anodyne  effect  and  can  be  applied  to  the  tenderest 
rectum  without  irritation. 


DRY  TREATMENT 


237 


Natural  Mineral  Waters. — The  thermal  waters  of  Carlsbad, 
Wiesbaden,  Ems  and  Neuenahr  are  likewise  worthy  of  frequent 
trial,  in  small  quantities,  100  to  200  Cc.  (3  to  7  ounces),  especially 
for  chronic  catarrh  of  the  large  intestine.  The  effects  of  these 
waters  are  dependent  partly  on  their  mucus-solvent  action,  but 
they  also  have  a  directly  beneficial  effect  on  the  intestinal  mucous 
membrane  in  catarrhal  conditions.  They  ma}'  also  be  employed  in 
the  treatment  of  ulcerative  processes. 

Dry  Treatment.- — Dry  local  treatment  of  catarrhal  and  ulcerative 
colitic  processes  has  been  highly  recommended  of  late.  This  treat- 
ment must  be  administered  with  the  assistance  of  the  sigmoido- 
scope, and  may  therefore  be  applied  only  as  far  as  the  sigmoid 
flexure.  Many  instruments  are  available  for  this  purpose;  the  one 
usually  employed  is  the  pneumatic   sigmoidoscope  (Fig.  46).     A 

d 


-s 


—  6 


Fig.  46. — Pneumatic  sigmoidoscope.  (Strauss.)  a,  metal  cylindrical  tube;  b, 
handle;  c,  double  rubber  bulb;  d,  electric  wires;  e,  staff  carrying  light;  /,  lamp;  g, 
glass  end-piece;  h,  obturator. 

metal  cylindrical  tube  (a)  35  centimeters  (12  inches)  long,  with 
a  handle  (b),  is  attached  to  a  double  rubber  bulb.  A  metal 
obturator  (h)  closes  the  inner  end  of  the  speculum  before  it  is  intro- 
duced into  the  rectum.  After  the  instrument  has  passed  through 
the  anal  canal,  the  obturator  (h)  is  removed  and  a  metal  staff 
(e)  carrying  an  electric  lamp  (/)  is  introduced  in  its  place.  An 
electric  wire  (d)  connects  the  lamp  with  a  storage  battery.  By 
attaching  the  glass  end-piece  (g)  and  gradually  inflating  the  rectum 
with  the  bulb  (c),  the  inside  of  the  rectum  can  be  easily  seen. 
The  further  introduction  of  the  instrument  is  simple,  because 
the  end  of  the  speculum  can  be  easily  pushed  along  the  lurnen  of 
the  bowel,  being  guided  by  the  eye  of  the  physician  through  the 
glass  end-piece  (g).  The  instrument  should  be  introduced  with 
the  patient  hi  the  knee-chest  position  (Fig.  47).     In  inflammatory 


238     INTRARECTAL    TREATMENT  OF  INTESTINAL   DISEASES 

and  ulcerative  processes  in  these  parts  of  the  gut,  the  sigmoidoscope 
is  pushed  beyond  the  diseased  portion  of  the  mucous  membrane  until 
normal  mucous  membrane  is  reached.    Under  the  control  of  the 


Fig.  47. — The  direction  of  the  sigmoidoscope  through  the  sigmoid  flexure,  the  patient 
in  the  knee-chest  position.     (Strauss.) 


Fig.  48. — Powder  blower.     (Rosenberg.) 


Fig.  49. — Powder  blower. 


PROCTOCLYSIS 


239 


eye,  and  while  slowly  removing  the  instrument,  the  entire  diseased 
portion  of  the  gut  is  covered,  by  means  of  a  powder  blower  (Figs. 
48  and  49),  with  a  thick  and  even  layer  of  some  active  astringent  or 
antiseptic  powder.  The  rectum,  of  course,  will  have  had  to  be 
cleansed  previously  by  washing  it  out  with  either  water  or  chamo- 
mile tea.  Rosenberg  recommends  as  a  medicinal  application  a 
mixture  of  tannic  acid  and  subgallate  of  bismuth  in  equal  parts,  or 
a  mixture  of  tannic  acid  and  magnesium  oxid  (15  to  30  parts  of  the 
former  to  100  of  the  latter).  Zweig  recommends  for  this  method  of 
treatment  equal  parts  of  tannic  acid  and  bismuth  subgallate,  and  a 
little  common  salt.  The  salt  is  in- 
tended to  assist  in  placing  the  powder 
as  high  up  as  possible  in  consequence  of 
its  well-known  action  in  stimulating 
reverse  peristaltic  movements.  Bismuth 
subnitrate  and  iodoform  are  likewise 
very  useful  powders. 

Proctoclysis. — Proctoclysis  or  "Mur- 
phy drip"  consists  of  the  gradual  intro- 
duction of  large  quantities  of  liquid 
into  the  rectum  by  the  drop  method. 
The  mucous  membrane  of  the  rectum 
absorbs  water  with  great  rapidity.  The 
liquid  must  be  introduced  without  pro- 
ducing overdistention,  because  this 
superinduces  spasm  and  the  expulsion 
of  the  introduced  liquid.  There  are 
many  instruments  employed  for  procto- 
clysis. The  simplest  is  the  one  devised 
by  Murphy.1  It  consists  of  a  fountain 
syringe  or  can  with  a  long  rubber  tube 
attached,  terminating  in  a  vaginal  hard- 
rubber  or  glass  tip  with  numerous  open- 
ings in  its  bulbed  end  (Fig.  50).  The 
tip  should  be  inserted  into  the  rectum 
so  that  the  bend  fits  closely  to  the 
sphincter. 

The  tube  may  be  held  in  position  by  the  use  of  adhesive  strips 
bound  to  the  thighs.  The  bag  is  suspended  ten  inches  above  the 
patient's  thighs.  When  the  apparatus  is  in  place  it  need  not  be 
disturbed  for  several  days.  Murphy  recommends  for  proctoclysis 
a  solution  of  a  teaspoonful  each  of  sodium  chlorid  and  calcium 
chlorid  in  a  "pint  of  water,  kept  at  a  temperature  of  100°  F.  by 
applied  heat  in  the  form  of  hot-water  bags,  an  encasing  can  of  hot 
water,  or  thermolytes.  .A  pint  and  a  half  of  water  every  two  hours 
can  be  easilv  introduced  in  this  manner. 


Fig.  50. — Proctoclysis  appa- 
ratus consisting  of  fountain 
syringe,  large  rubber  tube  and 
vaginal  hard  rubber  or  glass  tip. 


1  Journal  of  the  American  Medical  Association,  April  17,  1909. 


240    INTRARECTAL    TREATMENT  OF  INTESTINAL   DISEASES 

Elbrecht1  has  devised  an  apparatus  which  works  admirably  in 
adults.  For  the  maintenance  of  uniform  heat  the  apparatus  ful- 
fils all  indications.  There  is  usually  a  great  loss  of  heat  in  the 
rubber  tubing  from  the  reservoir  to  the  rectum ;  the  liquid  becomes 
cold  by  the  time  it  enters  the  rectum,  and  this  retards  absorption. 
The  Elbrecht  apparatus  (Fig.  51)  keeps  the  liquid  warm  and 
insures  the  greatest  possible  absorption  and  least  discomfort. 


Fig.  51. — Metal  heating  chamber,  block-tin  lined,  with  opening  for  electric  heat- 
ing unit  and  rubber  tube  connection  for  intake  and  outlet  of  saline  solution.  (One- 
third  size.) 

The  rectal  tips  shown  in  Fig.  52  are  made  in  four  sizes,  are  self- 
retaining,  and  admit  a  rectal  tube,  as  shown  in  Fig.  53;  thus  the 
saline  solution  can  be  discharged  several  inches  into  the  rectum. 
They  prevent  leakage  in  proctoclysis.  The  larger  sizes  are  for 
patients  with  relaxed  sphincter,  as  in  advanced  peritonitis,  shock, 
severe  toxemias,  etc. 


Fig.  52. — Self-retaining  rectal  tips,  made  in  four  sizes  of  hard  rubber,  with  opening 
through  center  to  admit  a  soft  rubber  rectal  catheter,  American  size,  No.  15.  (One- 
third  size.) 

Fig.  54  shows  a  screw  clamp  which  is  placed  on  the  rubber  tubing 
behind  the  glass  tube  connection  to  catheter,  to  regulate  the  flow 
of  water.  It  may  be  applied  to  any  part  of  the  tubing  without 
disturbing  the  apparatus  while  in  use,  and  is  left  wide  open  when 
the  gravity  method  is  used. 

1  Journal  of  the  American  Medical  Association,  November  16,  1909,  p.  1249. 


PROCTOCLYSIS 


241 


The  electric  heating  arrangement  is  the  cleanest  and  the  most 
satisfactory  (Figs.  55  and  56);  it  requires  little  or  no  attention 
when  once  started,  and  can  be  placed  in  the  bed  with  the  patient. 


Fig.  53. — Self-retaining  rectal  tips  on  catheter,  showing  how  adjustment  can  be 
accomplished  by  merely  drawing  catheter  through  to  desired  length.  (One-half  size 
of  largest  rectal  tip.) 


Fig.  54. — Metal  compressor  and  screw  to  regulate  the  flow  of  the  Murphy  drip. 


Fig.  55. — Electric  heating  unit  with  socket  connection  and  ten  feet  of  cord.  This 
unit  can  be  used  with  either  alternating  or  direct  current,  105  to  128  volts  (see  Fig. 
56).      (One-third  size.) 


The  same  results  can  be  obtained,  however,  where  electricity  is 
not  available,  as  in  rural  districts  or  in  homes  where  only  gas  is 
at  hand,  by  using  a  Bunsen  burner  or  an  alcohol  lamp  in  connection 
16 


242    INTRARECTAL   TREATMENT  OF  INTESTINAL   DISEASES 

with  the  heating  chamber,  which  is  then  placed  on  a  small  table 
alongside  the  bed  (Figs.  57  and  58). 

A  simple  and  inexpensive  glass  apparatus  (Fig.  59)  has  been 
devised  to  be  attached  to  an  ordinary  fountain  syringe  for  regulat- 
ing the  flow  of  water  by  allowing  it  to  drip.  The  tubing  of  the 
fountain  syringe  bag  is  attached  at  a  and  a  short  strip  with  rectal 
tips  at  exit  d.  The  number  of  drops  per  minute  can  be  regulated 
by  the  screw  (e)  on  the  compressor. 


Fig.  56. — Electric  heater  in  operation,  showing  it  properly  connected, 
glass  tube  connects  catheter  to  rubber  tubing.     (Elbrecht.) 


A  short 


Young1  suggests  an  apparatus  for  continuous  proctoclysis  that 
is  simple,  practical  and  inexpensive.  The  chief  difficulty  in  the 
management  of  continuous  proctoclysis  lies  in  the  maintenance 
of  the  temperature  of  the  solution  at  a  uniform  degree.  The  pos- 
sessor of  a  "thermos"  flask  is  provided  with  a  simple  means  of 


Fig.  57. — Heat  unit  for  alcohol  or  Bunsen-burner  flame  with  regulating  piston.     For 
use  where  electric  current  is  not  available  (see  Fig.  58).     (One-third  size.) 

overcoming  this  difficulty  (Fig.  60).  All  the  additional  apparatus 
necessary  is:  a  U-shaped  piece  of  glass  tubing  with  one  arm  long 
enough  to  reach  the  bottom  of  the  flask;  three  or  four  feet  of  rubber 

i  The  Lancet,  November  19,  1910,  p.  1517. 


NUTRIENT  EN  EM  AT  A 


243 


tubing  attached  to  one  end  of  the  glass  tube  and  connected  with 
the  catheter  by  the  other;  and,  lastly,  some  means  of  limiting  the 
flow,  such  as  a  metal  compressor  on  the  rubber  tube.  The  flask 
is  filled  with  the  solution  at  a  temperature  a  few  degrees  above 
that  at  which  it  is  desired  to  administer  the  injection,  and  sus- 
pended two  or  three  feet  above  the  patient's  bed.  The  fluid  is 
then  run  off  by  siphonage  and  the  flow  regulated  by  the  metal 
compressor.  The  temperature  of  the  solution  will  remain  at  a 
practically  uniform  level  while  the  bottle  slowly  empties.  At  the 
rate  usually  advised — namely,  one  drop  per  second — only  225  Cc. 
(7|  ounces)  are  used  per  hour,  so  that  a  pint  thermos  flask  will 
contain  sufficient  solution  to  last  two  hours. 


Fig. 


58. — Alcohol  or  gas  heater  in  operation,  showing  it  properly  connected. 
A  short  glass  tube  connects  catheter  to  rubber  tubing.     (Elbrecht.) 


Medicaments  and  nutrient  enemata  can  be  introduced  into  the 
rectum  at  will  by  protoclysis.  The  addition  of  20  per  cent,  of 
grape-sugar  not  only  adds  greatly  to  the  nutrition  but  also  assists 
in  the  absorption  of  other  nutrient  substances. 

Nutrient  Enemata. — It  is  now  known  that  nutrient  enemata  are 
not  completely  absorbed  by  the  rectum  or  colon,  and  the  degree 
of  absorption  and  assimilation  declines  as  the  period  of  rectal 
feeding  is  extended.  When  it  is  necessary  to  administer  nutrient 
enemata,  the  colon  should  be  thoroughly  cleansed  every  day  by  an 
injection  consisting  of  a  liter  (quart)  of  water  and  a  teaspoonful  of 
salt,  administered  early  in  the  morning.  Rectal  alimentation  may 
be  given  an  hour  later.    The  nutrient  enema  is  best  injected  by 


244    INTRARECTAL    TREATMENT  OF  INTESTINAL   DISEASES 

means  of  a  fountain  or  Davidson  syringe,  or  a  plain  hard-rubber 
piston  syringe  and  a  soft-rubber  rectal  tube  which  is  introduced 
into  the  anus  three  to  five  inches.  The  enema  (5  to  10  ounces) 
should  be  given  slowly  and  with  very  little  or  no  force,  in  order 
to  prevent  peristalsis,  which  would  result  in  emptying  the  lower 
bowel.  After  the  tube  is  withdrawn  from  the  rectum  the  patient 
should  be  requested  to  lie  quietly  and  to  endeavor  to  retain  the 
enema.    Three  to  five  such  enemata  may  be  administered  daily. 


-a 


—  e 


ct 


Fig.  59. — Glass  attachment  for  proctoclysis,     a,  glass  tube;  b,  glass  dropper;  c,  glass 
nozzle;  d,  glass  end  for  rectal  tube;  e,  compressor. 

When  enemata  are  continued  over  a  long  period  of  time  it  is  advis- 
able to  wash  out  the  rectum  at  least  once  a  day  with  warm  water, 
soapsuds,  or  boric  acid  solution;  by  this  means  all  foreign  matter 
is  got  rid  of,  feces  dislodged,  and  mucus  and  any  remains  of  former 
enemata  washed  away. 

The  rectum  and  colon  will  not  digest  ordinary  foods,  but  there 
are  certain  energy-producing  substances  that  can  be  absorbed  when 
given  as  nutrient  enemata.  No  attempt  should  be  made  to  give 
undigested    proteins.    The    aminoacids     should    be    derived    from 


MTh'IK.S  T  hISEMMW 


i'ir, 


artificially  digested  meat,  and  the  vitamin  should  be  obtained  from 
pancreas.  It  should  not  be  forgotten  that  alcohol  is  an  energy  food 
which  can  be  utilized  in  rectal  feeding,  but  it  must  not  be  given  in 
greater  concentration  than  5  per  cent.  The  composition  of  a 
nutrient  enema  that  can  be  easily  absorbed  and  duly  utilized,  with 
an  energy  value  of  750  calories,  is  as  follows: 

Gm.  or  Cc. 

Glucose 50  0 

Alcohol 50  0 

Calcium  chlorid 0  3 

Sodium  bicarbonate 3  0 

Sodium  chlorid 4  0 

Aminoacids  and  vitamins  as  much  as  desired. 

Distilled  water  to  make 1000 1 0 

Of  this,  400  or  500  Cc.  is  to  be  given  three  times  daily. 


Fig.  60. — Thermos  proctoclysis  apparatus,  a,  small  thermos  bottle;  b,  U-shaped 
glass  tube;  c,  rubber  tubing;  d,  glass  connection;  e,  catheter;  /,  metal  compressor  to 
regulate  flow;  g,  leather  strap  to  hang  thermos  bottle  to  foot  of  bed. 

A  large  number  and  variety  of  nutrient  enemata  have  been  devised. 
Those  most  commonly  used  and  shown  by  experience  to  be  most 
satisfactory  are: 

Glucose  or  grape-sugar.  A  great  number  of  calories  may  be 
introduced  by  this  means.  To  \  liter  (1  pint)  of  normal  saline, 
50  Gm.  (1|  ounces)  of  dextrose  may  be  added.    This  makes  a  10-per- 


246    INTRARECTAL   TREATMENT   OF  INTESTINAL   DISEASES 

cent,  solution.  This  quantity  can  be  introduced  every  six  hours  by 
proctoclysis.  In  twenty-four  hours  the  patient  would  receive  800 
calories. 

Moritz  recommends  15  Gm.  (§ss)  grape-sugar,  the  same  quantity 
of  malt  extract,  100  Cc.  (Siij)  milk,  6  Gm.  (3iss)  common  salt,  1 
wineglass  of  claret,  and  2  or  3  eggs. 

Of  peptones  or  propeptones  in  the  market,  about  two  or  three 
ounces  dissolved  in  six  to  eight  ounces  of  water  may  be  injected. 
The  different  beef  juices  may  also  be  diluted  with  water  and  injected 
in  corresponding  quantities. 

Six  to  seven  ounces  of  milk,  one  or  two  raw  eggs  well  beaten  up 
in  the  milk,  one  teaspoonful  of  powdered  sugar  and  one-third  of  a 
teaspoonful  of  common  table  salt,  make  a  nutritious  enema.  Pan- 
creatin  may  be  added  to  facilitate  assimilation  (Einhorn). 

Boas  recommends  eight  ounces  of  milk,  two  yolks  of  eggs,  com- 
mon salt,  one  tablespoonful  of  claret,  and  one  teaspoonful  of  flour. 

The  nutrient  enema  recommended  by  Ewald  consists  of  40 
Gm.  (5x)  of  wheat  flour  stirred  up  in  150  Cc.  (§v)  of  tepid  water 
or  milk.  To  this  mixture  are  added  one  or  two  eggs,  3  Gm.  (45 
grains)  of  sodium  chlorid,  and  50  to  100  Cc.  (§iss-iij)  of  a  15-  to 
20-per-cent.  solution  of  grape-sugar;  the  whole  is  thoroughly  beaten 
up.     Claret  may  be  added  as  required. 

For  hospital  practice  Strauss  recommends,  chiefly  on  the  ground 
of  economy:  8  ounces  of  bouillon,  1  ounce  of  alcohol,  1  ounce  of 
grape-sugar,  2  yolks  of  eggs,  |  teaspoonful  of  sodium  chlorid,  2  or  3 
tablespoonfuls  of  gum-arabic  mucilage. 

Leube  employs  enemata  consisting  of  well-chopped  meat  (5  ounces), 
fresh  pancreas  (2  ounces),  and  1  ounce  of  fat  (butter),  all  thoroughly 
mixed  with  about  6  ounces  of  water. 

Should  the  patient  experience  difficulty  in  retaining  an  enema 
administered  as  advised  above,  10  drops  of  simple  tincture  of 
opium  may  be  added  to  each  enema.  The  opium  has  a  quieting 
effect  upon  the  lower  bowel,  allaying  any  local  irritability  that 
may  exist.  The  addition  of  opium  to  the  enema  has  also  been 
recommended  for  its  influence  upon  the  nerve  control  of  thirst. 


CHAPTER  XII. 
HYDROTHERAPEUTICS— MINERAL  WATERS. 

HYDRIATIC   AND   THERMIC   TREATMENT. 

Hydrotherapeutics  constitutes  an  important  part  of  the  treat- 
ment of  diseases  of  the  digestive  organs.  Water  is  essential  to 
the  performance  of  all  the  physiologic  functions.  In  fact,  it  ranks 
first  among  the  therapeutic  resources.  It  may  be  used  as  a  drink, 
as  a  spray,  for  lavage,  or  as  a  douche,  and  externally  in  baths, 
packs,  moist  rubbing,  and  slapping. 

In  the  use  of  water  as  a  therapeutic  agent  the  physician  should 
have  clearly  in  mind  the  results  to  be  attained.  Cold  water  applied 
externally  should  have  a  stimulating  effect,  as  shown  by  the  skin 
reactions.  In  pathologic  conditions  of  the  stomach  and  intestine, 
the  stimulus  should  be  moderate  in  character.  Weak  stimuli 
tend  to  increase  vitality,  while  stronger  ones  have  an  inhibitory 
effect.  The  physician  should  exercise  great  precaution  in  the 
treatment  of  digestive  cases  complicated  with  anemia,  nervousness, 
and  debility.  In  moist  rubbing  and  slapping,  the  water  should  be 
below  body  temperature,  care  being  exercised  to  avoid  undue 
shock  to  sensitive  patients.  The  temperature  of  the  water  should 
vary  from  85°  to  60°  F.  The  wet  rub  is  best  given  early  in  the 
morning,  inasmuch  as  the  skin  reacts  best  at  this  time,  owing  to 
the  fact  that  it  is  uniformly  heated  on  rising.  The  patient  should 
stand  barefooted  on  some  non-conducting  substance,  such  as  a 
piece  of  carpet  or  a  cork  mat.  A  large  linen  sheet  wrung  out  of 
water  at  the  proper  temperature  is  placed  about  him  by  the  phy- 
sician or  attendant,  who  then  proceeds  to  rub  vigorously  his  back, 
arms,  and  legs.  The  patient,  meanwhile,  assists  by  rubbing  the 
chest  and  abdomen.  In  a  few  moments  this  should  be  followed 
by  an  agreeable  feeling  of  warmth.  The  patient  should  be  dried 
thoroughly,  and  should  either  rest  for  half  an  hour  or  take  a  short 
walk  before  breakfast. 

The  "rub -off"  is  made  as  follows:  The  patient  elevates  his 
arms,  and  is  wrapped  quickly  into  a  moist  linen  sheet — one  corner 
of  which  is  clamped  by  one  lowered  arm  while  the  sheet  is  wound 
around  to  overlap  it  and  is  clamped  under  the  other  arm  also. 
The  towel  is  then  wrapped  around  the  patient's  trunk  so  that 
the  shoulders  are  covered.  Energetic  rubbing  and  beating  are 
performed  by  the  attendant  with  the  palm  of  the  hand.  As  soon  as 
the  patient  experiences  a  feeling  of  warmth  he  is  released  from  the 
pack  and  rubbed  dry.  In  the  absence  of  an  attendant  the  patient 
may  dry  himself  by  rubbing  vigorously  with  a  Turkish  towel. 


248  HYDROTHERAPEUTICS— MINERAL  WATERS 

Should  the  skin  reaction  following  the  use  of  the  wet  pack  not 
be  well  marked,  before  another  treatment  the  temperature  of  the 
patient  should  be  raised  either  by  moderate  exercise  or  by  a  dry 
rub.  If,  after  this  procedure,  the  cold  rub  fails  to  bring  about 
a  skin  reaction,  it  should  be  omitted;  better  sponge  the  patient 
off  with  water  at  a  temperature  agreeable  to  his  sensitiveness — 
three  parts  water  to  one  of  vinegar,  or  one  part  alcohol  to  two  of 
water,  may  be  used.  The  bath  may  be  given  by  applying  the 
mixture  to  the  whole  body  before  attempting  to  dry,  or  a  portion 
of  the  body,  an  arm  or  a  leg,  may  be  bathed  and  then  dried,  and  so 
on  until  the  whole  body  has  participated  in  the  operation. 

Half  Baths. — What  are  known  as  half  baths  have  a  favorable 
and  stimulating  effect  upon  the  nervous  system.  The  patient 
sits  in  a  bath  tub  in  which  the  water  at  90°  F.  reaches  as  high  as 
his  umbilicus.  In  treating  more  robust  patients  the  temperature 
of  the  water  may  be  as  low  as  82°  or  77°  F.  The  patient  should 
immerse  himself  to  the  neck  in  the  water  and  return  to  the  sitting 
posture.  The  attendant,  assisted  by  the  patient,  proceeds  to  rub 
the  latter  vigorously.  The  whole  bathing  process  should  last  about 
three  or  four  minutes,  during  which  time  the  patient  should  be 
active.  On  stepping  out  of  the  tub  he  is  covered  with  a  dry  sheet 
and  rubbed  dry  while  either  sitting  on  a  chair  or  lying  in  bed. 
The  bath  may  be  followed  by  moderate  exercise  or  by  rest  in  the 
recumbent  posture  in  bed.  The  patient  should  experience  a  feeling 
of  comfort  after  each  treatment. 

The  half  bath,  so  called,  may  be  varied  in  several  ways.  The 
patient  may  sit  for  five  to  ten  minutes  immersed  to  the  neck  in 
water  at  a  temperature  of  84°  to  90°  F.  Then  the  water  is  allowed 
to  flow  out  of  the  tub  until  it  is  at  the  level  of  the  patient's  umbili- 
cus, when  the  attendant  begins  to  rub  him  and  sprinkle  him  with 
water.  The  half  bath  may  be  made  even  more  intense  and  stimu- 
lating by  allowing  cold  water  to  flow  into  the  tub  during  the  manip- 
ulations of  the  attendant.  In  all  these  procedures  the  head  should 
not  be  allowed  to  become  wet. 

Cold  Entire  Pack. — What  is  known  as  the  cold  entire  pack  pro- 
duces a  stimulating  and  refreshing  effect  when  it  is  employed 
under  proper  conditions.  A  large  flannel  blanket  is  spread  upon 
the  bed  or  couch,  and  over  it  a  sheet  which  has  been  dipped  into 
water  of  about  50°  to  60°  F.,  and  which  remains  fairly  saturated 
with  it.  After  the  morning  evacuation  of  the  bowels  and  bladder 
the  patient  is  packed  into  the  sheet  and  blanket  so  that  his  shoulders 
and  arms  are  included  in  the  folds.  A  stimulating  effect  is  produced 
by  removing  the  pack  as  soon  as  the  reaction  sets  in.  To  prolong 
the  duration  of  the  pack  beyond  this  point  produces  a  quieting 
effect  upon  the  patient,  so  that  sometimes  he  becomes  drowsy  and 
has  a  desire  to  sleep. 


HYDBIATIC  AND  THERMIC  TREATMENT  249 

Should  the  desired  reaction  not  take  place  after  the  cold  or  wet 
rub,  this  operation  may  be  preceded  by  the  eold  pack  until  the 
body  becomes  sufficiently  warmed. 

In  this  mode  of  hydrotherapeutic  treatment  of  patients  with 
gastro-intestinal  disease  we  note  at  first  a  slowing  of  the  temporal 
pulse,  which  soon  returns  to  the  normal  rate. 

To  avoid  hyperemia  in  the  head  or  in  the  region  of  the  heart, 
cold  compresses  may  be  applied  to  the  head,  or  the  cooling  appa- 
ratus of  Leiter  (Fig.  61)  may  be  applied  over  the  region  of  the 
heart. 

Warm  Entire  Pack.- — By  employing  lukewarm  water  in  our  hydro- 
therapeutic  treatment  we  may  obtain  a  sedative  effect.  The  blood- 
pressure  diminishes,  and  with  the  dilatation  of  the  bloodvessels  the 
painful  symptoms  are  alleviated.  The  patient  becomes  quiet,  and 
sleep  ensues. 

In  the  prolonged  warm  entire  pack  the  patient  is  packed  in 
cloths  which  have  been  dipped  into  water  of  from  95°  to  100°  F. 
Since  the  cloths  cool  off  rapidly,  this  pack  must  be  administered 
quickly. 

Prolonged  Baths. — The  prolonged  lukewarm  full  bath  acts  as  an 
agreeable  sedative  and  hypnotic.  The  temperature  of  the  water 
should  be  in  the  neighborhood  of  95°  F.  The  patient  should  be 
placed  in  a  comfortable  position,  preferably  reclining.  The  water 
should  reach  over  the  shoulders.  The  duration  of  the  bath  should 
be  from  five  to  twenty-five  minutes.  Should  the  bath  be  more 
protracted,  care  must  be  taken  that  the  water  does  not  cool  off 
too  much.  Any  kind  of  exertion  is  to  be  avoided,  both  before  and 
after  the  bath.  When  the  end  desired  is  the  induction  of  sleep, 
the  tepid  bath  is  best  employed  toward  evening  or  immediately 
before  retiring. 

The  prolonged  baths  may  be  medicated  by  the  addition  of 
various  chemical  agents.  Sodium  chlorid  may  be  used  with  the 
water  to  make  a  1-per-cent.  or  2-per-cent.  solution.  Carbon 
dioxid  at  times  exerts  a  beneficial  influence  upon  nervous  patients. 
The  carbon  dioxid  bath  may  be  prepared  in  private  homes  by 
the  combination  of  sodium  bicarbonate  with  mineral  acids  or 
with  acetic  acid.  Oxygen  baths  are  beneficial  in  the  treatment 
of  nervous  dyspepsia.  Such  baths  are  prepared  by  adding  sodium 
perborate  and  a  manganese  salt  to  the  water,  the  sodiuni  perborate 
being  broken  up  by  the  manganese  salt  in  the  presence  of  water, 
with  the  liberation  of  oxygen.  The  immersion  of  the  body  in  such 
an  effervescing  solution  gives  a  powerful  impetus  to  the  nervous 
system.  Many  patients  find  the  addition  of  250  to  500  grams  (§ 
to  1  pound)  of  pine-needle  extract  to  the  bath  very  agreeable,  but 
the  good  effect  is  probably  largely  mental. 

Indications. — The  indications  for  hydrotherapeutic  treatment 
in  diseases  of  the  digestive  organs  are  not  always  clear.     In  a 


250  HYDROTHERAPEUTICS—MINERAL  WATERS 

general  way  hot  applications  tend  to  the  diminution  of  pain  and 
have  an  antispasmodic  effect;  cold  applications,  on  the  other  hand, 
stimulate. 

Compresses. — Hot  compresses  in  the  form  of  poultices  are  well 
known  to  the  laity.  To  prepare  a  mashed-potato  poultice,  which 
is  one  of  the  best  forms  of  cataplasm,  freshly  cooked  potatoes  are 
placed  upon  a  piece  of  cheesecloth,  a  portion  of  which  is  folded 
in  the  form  of  a  sac.  This  bag  may  be  closed  by  means  of  safety 
pins  or  a  few  stitches.  The  potatoes  are  crushed  with  a  wooden 
roller,  after  which  the  poultice  is  ready  for  use.  This  poultice  is 
not  only  the  cleanest,  but  retains  its  warmth  longer  than  any  other. 

Linseed  poultices  are  made  by  boiling  the  linseed  meal  to  a 
thick  consistency.  The  mass  is  then  folded  into  the  cloth  and 
used  in  the  same  manner  as  the  potato  poultice.  The  linseed 
poultice  is  not  so  satisfactory,  owing  to  the  fact  that  it  adheres 
to  the  parts  and  is  apt  to  undergo  acid  fermentation. 

It  is  hardly  necessary  to  say  that  cataplasms  should  always 
be  applied  hot  and  of  sufficient  size  to  cover  the  portion  of  the 
abdomen  involved.  To  secure  the  desired  effect,  two  poultices 
should  be  prepared,  so  that  one  may  be  in  the  steam  bath  while 
the  other  is  doing  duty  on  the  patient.  To  maintain  the  hea't, 
double  boilers  are  very  convenient.  The  cataplasm  is  placed  in 
a  tray  with  a  perforated  bottom  held  above  the  water  level  in  the 
boiler.  The  water  may  be  heated  by  a  spirit  lamp  or  other  means, 
so  that  the  poultice  when  not  in  use  is  subjected  to  the  action  of 
steam.    The  apparatus  should  be  kept  covered. 

Heat  may  be  applied  to  the  abdominal  region  by  means  of  hot 
towels,  or  heated  plates  well  wrapped  in  cloth.  The  flat  stomach- 
bottle,  of  aluminum,  rubber,  or  zinc,  is  of  practical  value.  Flat 
rubber  bottles  or  boxes  filled  with  some  chemical  substance  are 
obtainable,  which,  after  being  subjected  to  the  action  of  boiling 
water  for  fifteen  minutes,  will  retain  their  heat  for  several  hours. 
Electric  warming  pads  and  electrothermic  bottles  are  of  more 
recent  invention.  Leiter's  tubes  (Fig.  61)  are  made  of  tin,  alumi- 
num, or  hard  rubber;  they  are  placed  upon  the  abdomen  of  the 
patient,  and  hot  water  is  allowed  to  run  through  the  coil.  The 
electrothermic  bottle,  electric  warming  pad,  or  Leiter's  coils  may  be 
converted  into  moist  hot  compresses  by  encasing  them  in  moistened 
folds  of  cloth.  The  temperature  of  the  hot  cataplasm  must  be 
modified  according  to  the  requirements  of  the  patient's  comfort. 

When  hot  cataplasms  are  used  for  a  long  period  of  time,  for 
instance  in  gastric  ulcer,  the  skin  over  the  hypogastric  region  should 
be  thoroughly  cleansed  with  soap  and  water  and  weak  bichlorid 
solution,  and  a  piece  of  flannel  or  linen  laid  over  the  parts  and  made 
secure  by  adhesive  plaster.  This  forms  a  basis  for  the  hot  com- 
press.   In  this  way  blisters  from  heat  may  be  avoided. 

The  Priessnitz  bandage  is  applied  moist,  and  either  hot  or  cold, 


MYDRIATIC  AND  THERMIC  TREATMENT 


251 


so  that  it  produces  a  hyperemic  condition  of  the  skin.  The  appli- 
cation of  this  bandage  is  accompanied  by  an  agreeable  feeling  of 
warmth.  The  effect  is  sedative,  analgesic,  and  frequently  hypnotic. 
The  Priessnitz  bandage  consists  of  a  towel  folded  several  times, 
dipped  in  warm  water,  and  wrung  out.  This  is  placed  over  the 
stomach  and  covered  by  oiled  silk  or  gutta-percha,  with  a  flannel 
binder  to  retain  it  in  place.  This  bandage,  which  should  be  suffi- 
ciently tight  not  to  slip  down,  is  adjusted  at  night  and  allowed  to 
remain  on  the  patient  until  morning.  Alcohol  (50  per  cent.)  has  a 
more  stimulating  effect  than  water. 


Fig.  61. — Coiled  tubing.     (Leiter.) 


In  the  treatment  of  nervous  diseases  of  the  gastro-intestinal  tract, 
Winternitz  recommends  the  use  of  coiled  tubing,  such  as  the  Leiter 
cooling  apparatus,  in  which  water  at  a  temperature  of  55°  to  130°  F. 
is  allowed  to  circulate.  The  coils  are  interposed  between  moist 
linen  and  woolen  bandages  (Fig.  61). 

Douches. — Douches  are  often  applied  externally  with  good  effect. 
We  have  the  fan  douche  and  the  so-called  Scotch  or  interrupted 
douche.  A  somewhat  cumbersome  apparatus  is  required  for  the 
application  of  the  latter.  With  this  apparatus  the  temperature 
may  be  quickly  alternated  from  100°  to  50°  F.  and  an  interrupted 
jet  of  water  thrown  over  the  region  of  the  stomach.    We  obtain 


252  HYDROTHERAPEUTICS— MINERAL  WATERS 

by  the  use  of  this  apparatus  not  only  alternate  contraction  and 
dilatation  of  the  capillaries  of  the  skin,  but  reflex  contractions  of 
the  abdominal  muscles  as  well.  A  stimulus  is  likewise  given  to  the 
peristaltic  movements  of  the  intestine. 

MINERAL  WATERS. 

An  extensive  therapy  for  diseases  of  the  stomach  and  intestine 
is  provided  by  the  so-called  mineral-water  cures,  bath  cures,  climate 
cures,  and  sea  baths.  Mineral  waters  are  solutions  of  salts  and 
gases  in  water.  As  a  rule  the  solid  constituents  (salts)  are  present 
in  very  small  amounts.  In  spite  of  the  fact  that  these  waters 
are  among  our  oldest  therapeutic  agents,  we  have  much  to  learn 
in  regard  to  their  physiologic  action.  We  have  as  yet  no  well- 
defined  scientific  basis  of  procedure  in  regard  to  their  use.  Such 
investigators  as  von  Noorden,  Dopper,  Lareche,  Jaworski,  Boas, 
and  Wolf  have  sought  to  point  out  the  direct  local  and  systemic 
effects,  but  their  results  have  been  contradictory.  In  the  absence 
of  scientific  data  we  must  continue  to  base  our  use  of  mineral 
waters  on  empirical  knowledge,  controlled  only  by  what  we  know 
of  their  individual  constituents. 

The  gaseous  constituents  are,  chiefly,  carbon  dioxid  and  sul- 
phuretted hydrogen.  Some  of  the  waters  are  radio-active.  The 
solid  constituents  are  salts  of  sodium,  potassium,  magnesium,  alumi- 
num, calcium,  iron,  iodin,  bromin,  chlorin,  and  sulphur.  Some  of 
these  waters  have  a  purgative  effect,  some  laxative,  and  some 
diuretic. 

Classification.- — 1 .  Alkaline  chlorin  waters. 

2.  Sodium  chlorid  waters. 

3.  Alkaline  carbonated  waters. 

4.  Ferruginous  or  chalybeate  waters. 

5.  Bitter  waters. 

Alkaline  Chlorin  Waters. — Waters  from  the  alkaline  chlorin 
springs  contain  principally  sodium  chlorid,  sodium  sulphate, 
sodium  bicarbonate,  and  carbon  dioxid.  In  the  United  States 
we  have  Arondack,  at  Saratoga,  N.  Y.;  Bedford,  at  Bedford,  Pa.; 
Berry  Hill,  Elkwood,  Va.;  Crab  Orchard,  Kentucky;  French  Lick, 
Indiana;  Gate  Springs,  Tennessee;  West  Baden,  Indiana;  Hot 
Sulphur  Springs,  Colorado;  Gibson's  Mineral  Wells,  Texas;  and 
Ferris  Hot  Springs,  Montana.  To  this  class  belong  the  springs  of 
Carlsbad,  Bertrich,  Marienbad,  Rohitsch,  Tarasp,  and  Franzens- 
bad,  in  Europe. 

Carlsbad  and  Bertrich  are  warm  springs.  Carlsbad  is  especially 
famous  in  connection  with  the  treatment  of  diseases  of  the  stomach, 
liver,  and  intestine.  It  has  been  found  that  a  single  dose  or  a  few 
small  doses  of  Carlsbad  water  or  salt  will  excite  a  copious  secretion 
of  acid,  but  that  larger  doses  continued  for  a  longer  period  of  time 


MINERAL  WATERS  253 

may  greatly  diminish  the  secretion  of  gastric  juice.  Carlsbad 
water  stimulates  the  liver,  dissolves  mucus,  increases  the  peristaltic 
action  of  the  stomach  and  intestine,  and,  owing  to  its  warmth, 
diminishes  gastric  sensitiveness. 

The  individual  Carlsbad  springs  vary  in  temperature.  The 
springs  with  moderate  temperatures  are  preferable  to  those  with 
higher  degrees  of  heat,  especially  for  the  treatment  of  ulcer  of  the 
stomach.  These  waters  are  valuable  in  the  treatment  of  chronic 
gastritis,  especially  when  there  is  a  copious  secretion  of  mucus, 
and  in  hyperacidity  not  of  nervous  origin.  The  employment  of 
small  doses  of  the  very  hot  springs  in  catarrhal  affections  of  the 
biliary  passages  and  of  the  small  and  large  intestine  is  recommended. 

The  good  results  following  the  use  of  the  Carlsbad  waters  are 
partly  due  to  the  excellent  diet  prescribed  at  Carlsbad  resorts. 

Sodium  Chlorid  Waters. — In  the  United  States  are  the  Springs 
at  Ballston,  N.  Y.;  Hathorn,  Congress,  Kissingen,  Selters,  and 
Champion,  at  Saratoga,  New  York;  Colorado  Springs,  Colorado; 
Wasatko  Springs,  Utah;  and  in  Canada  the  springs  at  St.  Catha- 
rines, Ontario.  In  Europe  are  the  springs  of  Kissingen,  Homburg, 
Soden,  Wiesbaden,  Pyrmont,  and  Mergentheim. 

Sodium  chlorid  taken  after  a  meal  has  the  effect  of  inhibiting 
hydrochloric  acid  secretion  and  peptic  digestion  without  interfer- 
ing in  any  way  with  the  motility  of  the  stomach.  Experiments 
with  sodium  chlorid  waters,  especially  Kissingen  and  Homburg,  on 
patients  with  gastric  and  intestinal  disease,  have  shown,  on  the 
contrary,  that  in  cases  of  gastritis  with  subacidity  the  acid  secretion 
was  increased;  while  in  hyperacidity  the  employment  of  sodium 
chlorid  waters  is  frequently  followed  by  a  marked  decrease  in 
the  hydrochloric  acid  secretion.  Their  effects  in  subacid  condi- 
tions seem  to  be  fairly  constant,  that  is,  stimulating  the  secretion 
of  free  hydrochloric  acid;  but  observers  are  at  variance  regarding 
their  effects  in  hyperacidity.  In  subacidity  with  profuse  mucous 
secretion  the  sodium  chlorid  waters  cause  a  marked  diminution 
in  the  amount  of  mucus. 

In  cases  of  subacid  gastritis,  especially  in  their  incipiency,  the 
secretion  of  hydrochloric  acid  may  be  restored  to  normal  by  a 
course  of  treatment  with  the  sodium  chlorid  waters.  To  obtain 
the  favorable  effect  on  the  gastric  secretion,  the  waters  (Saratoga, 
Kissingen,  Wiesbaden)  should  be  taken  on  an  empty  stomach, 
and  the  patient  should  refrain  from  partaking  of  food  until  they 
have  passed  out  of  the  stomach. 

Alkaline  Carbonated  Waters. — The  alkaline  carbonated  waters  con- 
tain as  their  chief  constituents  sodium  bicarbonate  and  carbon 
dioxid.  The  principal  waters  of  this  class  in  the  United  States 
are:  Allouez,  Green  Bay,  Wis.;  Peerless,  Saratoga,  N.  Y.;  Vichy, 
at  Saratoga;  Skaggs,  Hot  Springs,  Cal.;  Canon  City,  Colorado. 
In  Europe  are  Bilin,  Fachingen,  Xeuenahr,  Giesshiibel,  Geilnou, 


254  HYDROTHERAPEUTICS— MINERAL  WATERS 

Preblau,  Salzbrunn,  and  Vichy.  Owing  to  the  fact  that  these 
waters  contain  sodium  carbonate,  they  are  indicated  particularly 
in  the  treatment  of  hyperacidity,  hypersecretion,  and  eructations. 
After  a  course  of  treatment  with  the  alkaline  carbonated  waters, 
particularly  Vichy,  an  increase  in  the  motility  of  the  stomach  has 
been  noted.  It  is  important  that  these  waters  be  administered 
warm,  to  lessen  the  sensitiveness  of  the  stomach. 

The  alkaline  saline  waters  contain,  in  addition  to  carbon  dioxid 
and  bicarbonate  of  sodium,  small  quantities  of  sodium  chlorid. 
In  the  United  States  are  Deep  Rock  Springs,  Oswego,  N.  Y.; 
Manitou,  Manitou,  Col.;  and  Sheboygan,  Sheboygan,  Wis.  They 
increase  the  secretion  of  gastric  juice,  and  are  indicated  in  chronic 
gastritis,  slight  atony,  and  secondary  catarrhs. 

Ferruginous  Waters. — These  waters  contain  bicarbonate  of  iron 
and  sulphate  of  iron.  The  ferruginous  springs  of  the  United  States, 
are:  Mardela,  Maryland;  Rock  Enon,  Virginia;  Church  Alum, 
Virginia;  Owosso,  Michigan;  Sparta  Mineral  Wells,  Wisconsin; 
Fruitport  Wells,  Michigan;  Wllbot,  Oregon;  Millboro,  Virginia; 
Rockbridge,  Virginia;  Mono  Lake,  California;  Bath  and  Bedford 
Alum,  Virginia.  In  Europe  there  are  the  acid  iron  springs  of 
Elster  and  Franzensbad,  and  the  waters  of  Reinerz,  Rippoldsau, 
Schwalbach,  and  Bartfeld.  These  waters  are  useful  in  the  treat- 
ment of  chronic  gastro-intestinal  catarrh  occurring  in  anemia  and 
chlorosis. 

Bitter  Waters. — Bitter  waters  are  indicated  in  the  treatment  of 
diseases  of  the  stomach,  liver,  gall  bladder,  and  intestinal  disease 
when  constipation  is  present.  They  inhibit  the  secretion  of  gastric 
juice.  Their  use  is  contra-indicated  in  gastric  ulcer.  Among  the 
bitter  waters  we  have  Abilena,  Franz  Josef,  Pluto,  Veronica, 
Arondack,  Saratoga,  and  West  Baden  Sprudel. 

Drinking  Cures. — We  possess  but  a  vague  knowledge  concerning 
the  mode  of  action  of  the  drinking  mineral  water  cures,  which 
are  so  often  undertaken,  and  frequently  with  good  results,  in  the 
treatment  of  gastro-intestinal  disease.  The  beneficial  effect  of 
particular  mineral  waters  has  generally  been  ascertained  empiri- 
cally. It  seems  impossible  to  clearly  understand  in  what  peculiar 
manner  these  waters  affect  intestinal  disorders.  As  in  the  dietetic 
treatment  (see  Chapter  VII),  so  with  the  mineral  waters,  the  pur- 
pose is  to  produce  either  a  purgative  or  a  constipating  action.  The 
former  is  brought  about  by  acceleration  and  the  latter  by  retarda- 
tion of  peristalsis.  Moreover,  the  waters,  to  a  certain  extent, 
produce  their  effects  mechanically,  inasmuch  as  they  wash  out 
the  bowel  and  remove  the  mucus,  bacteria,  and  decomposition 
products. 

The  action  of  purgative  waters  is  most  easily  understood.  It 
may  be  stated  in  a  general  way  that  every  one  of  the  mineral  waters 
is  capable  of  exerting  a  purgative  effect  when  taken  cold  and  in 


MINERAL  WAT  BUS  255 

large  doses.    The  purgative  effect  of  the  alkaline  acidulous  and 

the  alkaline  chlorid  waters  is  so  slight  that  they  are  not,  as  a  rule, 
taken  with  this  object  in  view.  They  contain  large  quantities  of 
carbon  dioxid,  which  increases  the  peristaltic  action  of  the  stomach 
and  intestine.  The  sodium  chlorid  waters  act  better  as  piugatives, 
and  the  effect  is  always  more  marked  from  the  cold  than  from  the 
warm  springs.  The  bitter  waters  are  the  most  effective  purgative 
waters  we  possess.  They  resemble  each  other  in  their  action, 
which  is  identical  with  that  of  the  saline  salts,  sodium  sulphate  and 
magnesium  sulphate.  The  pine  salts  are  not  adapted  to  prolonged 
use,  being  apt  to  induce  intestinal  catarrh  and  digestive  disturbances. 
The  sodium  sulphate  waters  are  well  borne  for  a  long  time,  have  a 
mildly  purgative  action,  and  in  small  doses  contribute  to  the  cure 
of  chronic  intestinal  catarrh,  because  the  sodium  sulphate  is  in  com- 
bination with  bicarbonate  of  sodium,  sodiiun  chlorid,  and  carbon 
dioxid.  The  thermal  springs  of  Carlsbad  are  particularly  famous 
because  of  their  good  effects  in  chronic  intestinal  catarrh.  The 
thermal  springs  of  Bertrich  and  the  artificial  Carlsbad  salt  act 
similarly.  These  waters  and  salts,  taken  warm,  are  specially  indi- 
cated in  chronic  gastric  catarrh  with  accompanying  constipation. 
They  are  likewise  indicated  in  chronic  catarrh  associated  with 
diarrhea;  in  such  cases,  however,  they  must  be  taken  in  small  doses 
and  as  hot  as  possible.  When  the  waters  and  salts  of  Carlsbad  and 
Bertrich  are  taken  cold,  the  purgative  effect  is  more  pronounced. 
Some  of  the  waters  contain  more  sodium  sulphate  than  Carlsbad, 
and  are  consequently  strongly  purgative,  especially  when  taken  cold. 
These  waters,  therefore,  are  often  prescribed  in  cases  of  hemorrhoids 
and  chronic  constipation  in  robust  patients. 

Two  opposing  theories  are  maintained  as  to  the  mode  of  action 
of  the  bitter  waters.  According  to  one  theory,  the  liquid  form  of 
the  stools  is  caused  by  transudation  and  dilution  in  obedience  to  the 
laws  of  osmosis.  The  other  theory  assumes  that  the  dilution  of 
the  feces  is  the  effect  of  an  increased  activity  of  the  glandular 
elements,  stimulated  by  improved  circulation  of  the  blood.  Gen- 
erally speaking,  the  bitter  waters  are  not  well  adapted  to  protracted 
use;  their  continued  administration  is  apt  to  cause  disturbances 
of  digestion  and  a  diminution  of  the  secretion  of  gastric  juice. 

Purgative  waters  should,  as  a  rule,  be  taken  in  the  morning 
on  an  empty  stomach,  one  hour  before  breakfast.  Bodily  activity 
during  the  interval  is  an  adjuvant  to  the  efficacy  of  the  waters. 
A  Carlsbad  cure  generally  requires  four  weeks.  Such  cures  may 
be  undertaken  equally  well  at  home  when  the  domestic  arrangements 
permit  of  fulfilling  the  requirements  as  to  diet  and  rest. 

Purgative  mineral  waters  are  able  to  produce  a  constipating 
effect  when  taken  very  hot  in  cases  of  intestinal  catarrh  with 
diarrhea  or  with  alternating  diarrhea  and  constipation.  They 
have  a  decidedlv  beneficial  effect  on  the  catarrhal  condition,  and 


256  HYDROTHERAPEUTICS— MINERAL  WATERS 

thus  on  the  diarrhea,  improving  the  form  of  the  fecal  discharge. 
The  other  sodium  sulphate  springs,  the  sodium  chlorid  waters, 
and  under  certain  conditions  the  alkaline  chlorin  acidulous  waters, 
occasionally  act  in  a  similar  manner.  Peristalsis  may  also  be 
reduced  by  the  calcium  and  ferruginous  waters. 

The  ferruginous  waters,  both  those  containing  carbon  dioxid 
and  those  containing  sulphates,  are  employed  in  cases  of  chronic 
diarrhea  and  catarrh,  especially  when  the  patient  is  more  or  less 
anemic.  The  waters  containing  calcium,  magnesium,  and  sodium, 
known  as  acid  waters,  are  used  in  relaxed  conditions  of  the  mucous 
membrane,  particularly  in  cases  characterized  by  diarrhea.  Very 
obstinate  cases  of  chronic  diarrhea  have  been  cured  by  a  sojourn 
at  a  spring  rich  in  calcium  bicarbonate.  The  ferruginous  waters 
increase  the  amoimt  of  hemoglobin.  They  also  increase  the  appe- 
tite and  reduce  intestinal  activity.  Such  waters  are  excellent  as 
tonics  and  valuable  in  the  treatment  of  diarrhea. 

Generally  speaking,  it  may  be  stated  that  mineral  water  drinking 
cures  are  indicated  in  catarrhs  of  the  stomach,  biliary  passages, 
and  small  and  large  intestine.  Carlsbad  waters  are  especially 
valuable  in  these  conditions.  In  hemorrhoidal  diseases  cold 
sodium  chlorid  springs  are  indicated,  while  in  chronic  diarrhea 
hot  sodium  chlorid  waters  and  the  Carlsbad  alkaline  chlorin 
waters  are  valuable.  Calcium  and  ferruginous  waters  are  indicated 
in  diarrhea.  In  light  forms  of  chronic  constipation  the  cold  sodium 
sulphate  springs  may  effect  a  permanent  cure.  On  the  other  hand, 
drinking  cures  are  usually  ineffective  in  all  grave  and  old  cases  of 
chronic  constipation  or  chronic  catarrh  and  diarrhea.  Such  cases 
should  be  placed  in  bed  at  home  or  in  a  good  private  sanitarium 
where  the  diet  is  regulated  in  a  proper  manner  and  where  other 
curative  agencies  may  be  utilized.  Home  drinking  cures  may  be 
instituted  as  a  preliminary  trial  before  going  to  the  location  of  the 
springs. 

All  mineral  waters  should,  by  preference,  be  taken  at  the  springs 
themselves;  it  is  a  matter  of  experience  that  the  waters  affect 
the  patients  more  favorably  when  this  is  done.  At  these  resorts 
the  patient  is  free  from  excitement  and  business  cares;  his  sur- 
roundings, the  atmosphere  and  the  scenery  are  conducive  to  peace  of 
mind,  and  dietary  regulations  are  more  apt  to  be  faithfully  carried 
out  than  at  home.  The  waters  may,  however,  be  taken  at  home  if 
a  sojourn  at  the  springs  is  impossible. 

As  a  fundamental  principle  no  systematic  mineral  water  treat- 
ment in  gastro-intestinal  disease  should  be  recommended  until 
a  diagnosis,  or  at  least  careful  examinations,  including  a  thorough 
chemical  analysis  of  the  stomach  contents,  and  in  many  cases  of  the 
feces  too,  have  been  made. 

Mineral  Baths,  Sea  Baths,  Climatic  Cures. — Bath  cures  are  gener- 
allv  combined  with  drinking  cures,  but  they  often  act  beneficially 


MINERAL  WATERS  257 

without  them.  They  have  ;i  favorable  influence  on  tissue  meta- 
morphosis, the  activity  of  the  skin  and  the  nervous  system,  thus 
reflexly  rather  than  directly  modifying  the  gastro-intestinal  disease. 
Salt  and  mud  baths  have  been  found  efficacious  in  the  treatment 
of  gastro-intestinal  affections.  Waters  containing  enough  sodium 
ehlorid  to  raise  their  specific  gravity  are  designated  salt.  Baths 
in  such  waters  are  of  three  kinds — weak  (1-  or  2-per-cent.  salt), 
medium  (up  to  6  per  cent.),  and  strong  (above  6  per  cent.). 
Three-per-cent.  mineral  salt  solutions  are  employed  for  bathing. 
Sea  baths  have  a  favorable  effect  in  inflammatory  and  exudative 
processes  of  the  stomach  and  intestinal  tract,  as  well  as  in  cases 
of  chronic  peritonitis.  Mud  baths  are  very  retentive  of  heat, 
conserving  and  prolonging  the  caloric  effect  upon  the  skin.  They 
act  locally  apart  from  the  general  stimulating  effect,  for  they  seem 
to  be  able  to  absorb  inflammatory  exudates.  Upon  this  fact  depends 
their  value  in  irritable  conditions  of  the  stomach,  pylorospasm, 
gastric  ulcer,  gastric  neuroses,  and  intestinal  adhesions. 

Many  of  the  waters  are  radio-active  and  their  virtue  may  be 
due  to  this  fact.  It  is  assumed  that  radio-activity  stimulates 
metabolism  and  exercises  an  influence  upon  the  internal  secretory 
•glands.  Radium  is  a  very  unstable  element,  continually  changing 
into  another  elementary  body.  Each  atom  of  radium  furnishes 
one  atom  of  helium.  Just  as  soon  as  helium  is  shot  out,  the  atom 
radium  changes  to  a  gas  to  which  the  name  radium  emanation  or 
niton  has  been  given.  Niton  is  a  hundred  thousand  times  more 
active  than  radium.  The  calculable  value  of  a  radio-active  mineral 
water  depends  upon  the  degree  of  its  radio-activity.  It  has  already 
been  found  that  these  baths  are  definitely  contra-indicated  in  cases 
of  tuberculosis  and  nephritis. 

Sea  baths  are  indicated  for  patients  with  digestive  disturbances 
due  to  neurasthenic  conditions,  gastric  atony,  or  ptosis.  Cold 
sea  baths  have  a  tonic  effect,  due  largely  to  the  salt  they  contain 
and  to  the  movements  of  the  waves.  They  stimulate  gastric 
digestion.  Well-nourished  patients  suffering  from  neuroses,  as 
well  as  the  anemic,  do  well  at  the  seaside.  Organic  intestinal 
diseases  (catarrh)  are  not  suitable  for  either  the  seashore  or  the 
mountains,  for  the  simple  reason  that  the  patients  do  not  there 
obtain  the  proper  diet.  Every  case  must  be  decided  on  its  own 
merits  when  a  choice  is  to  be  made  between  sending  a  patient  to 
the  seashore  or  to  the  mountains.  Generally  speaking,  patients 
of  sedentary  habits  are  better  off  in  the  mountains  than  at  a  seaside 
resort.  It  is  self-evident  that  climatic  cures  may  be  combined  with 
the  drinking  cure. 

Change  of  climate  and  residence  in  high  altitudes  are  most 
suitable  for  gastro-intestinal  patients  who  are  likewise  suffering 
from  mental  overwork  and  nervousness. 

27 


CHAPTER  XIII. 
MEDICATION  IN  GASTRIC  DISEASES. 

Hydrochloric  Acid  and  Pepsin. — Hydrochloric  acid  has  always 
been  regarded  as  an  available  therapeutic  agent  in  the  treatment 
of  certain  forms  of  gastritis,  especially  those  characterized  by 
deficiency  of  acid  secretion.  Clinicians,  however,  have  been  at 
variance  in  regard  to  the  quantity  that  should  be  administered. 
Some  have  doubted  the  advisability  of  giving  it  in  certain  forms 
of  subacidity,  maintaining  that  in  subacid  conditions  pepsin  is 
always  present  and  that  the  therapeutic  requirements  of  the  patient 
can  best  be  met  by  a  carefully  selected  dietary.  A  small  minority 
greatly  restrict  the  administration  of  hydrochloric  acid  while  at 
the  same  time  they  abandon  the  use  of  pepsin  altogether.  They 
argue  that  artificial  aids  to  digestion  are  not  necessary,  and  that 
their  habitual  use  is  to  a  certain  extent  injurious.  Every  organ, 
we  are  told,  is  strengthened  by  activity  and  weakened  by  lack  of 
exercise. 

It  is  important,  when  considering  the  effect  of  hydrochloric 
acid,  to  take  into  account  how  the  ingested  food  becomes  mixed 
with  the  acid  in  the  stomach.  The  mixing  varies,  according  to 
whether  the  hydrochloric  acid  has  been  taken  medicinally  or 
secreted  by  the  mucous  membrane  of  the  stomach  itself.  In  artifi- 
cial acidification  the  degree  of  admixture  depends  also  upon  the 
interval  of  time  between  the  ingestion  of  the  nutrient  and  the 
administration  of  the  acid. 

Hydrochloric  acid  may  be  taken  immediately  after  the  inges- 
tion "of  food,  or  a  few  minutes  later  (10,  15,  20);  by  giving  small 
doses  at  frequent  intervals,  which  is  the  usual  practice,  the  normal 
process  of  secretion  of  hydrochloric  acid  is  imitated.  Hydrochloric 
acid  may  be  taken  during  the  meal.  Its  admixture  with  the  food 
is  probably  accomplished  best  when  it  is  so  taken,  as  it  can  thus 
reach  every  particle. 

By  experiment  it  has  been  found  that  hydrochloric  acid  taken 
internally  has  the  power  to  stimulate  the  secretion  of  the  ferments 
of  the  stomach.  This  is  brought  about  by  the  action  of  the  acid 
on  the  pylorus  producing  a  secretin,  which  in  turn  being  absorbed 
stimulates  the  secretion  of  gastric  juice.  It  has  also  been  found 
that  ingested  hydrochloric  acid  will  directly  stimulate  the  secre- 
tion of  hydrochloric  acid  by  the  depraved  gastric  mucous  membrane, 
and  that  the  ingested  acid  makes  it  possible  for  the  gastric  mucous 
membrane  to  respond  with  an  increased  formation  of  acid  on  the 


HYDROCHLORIC  ACID  AND  PEPSIN  259 

introduction  of  food.  These  statements  refer  to  the  pathologically 
changed  gastric  mucous  membrane  only  (subacidity  in  gastritis). 

Experimental  research  has  shown  that  extensive  proteolysis 
cannot  be  obtained  by  the  administration  of  hydrochloric  acid 
alone;  pepsin  must  be  given  simultaneously.  It  was  formerly 
assumed  that  the  administration  of  pepsin  was  useless,  since  such 
a  small  amount  of  pepsin  is  necessary  to  proteolysis — for  when 
free  hydrochloric  acid  was  absent,  some  pepsin  or  its  precursor, 
pepsinogen,  was  found  in  the  stomach,  though  only  in  minute 
quantity.  In  order  to  secure  activity  of  the  pepsin,  or  pepsinogen, 
by  the  introduced  hydrochloric  acid,  it  is  necessary  that  these 
two  become  mixed;  this  important  fact  has  often  been  totally 
ignored. 

The  administration  of  pepsin  alone  is  of  but  little  therapeutic 
value.  After  reaching  the  stomach  it  comes  in  contact  with  the 
hydrochloric  acid  at  a  few  points  only — on  the  outer  border  of 
the  stomach  contents — and  can  therefore  exert  its  proteolytic 
action  nowhere  else.  Pepsin  given  alone  soon  passes  into  the 
intestine  without  having  assisted  materially  in  the  digestion  of  the 
food.  It  is  absolutely  useless  to  prescribe  pepsin  alone  in  cases  in 
which  hydrochloric  acid  is  not  furnished  by  the  stomach. 

Hydrochloric  acid  assists  the  intestinal  digestion  of  protein 
to  the  extent  that  protein  substances  which  have  been  treated 
previously  with  pepsin  and  hydrochloric  acid  can  be  digested 
much  better  with  trypsin.  Besides  this,  hydrochloric  acid  acts 
upon  some  precursor  in  the  duodenum,  producing  an  intestinal 
secretin  or  hormone,  which,  being  absorbed,  stimulates  the  secretion 
of  pancreatic  juice. 

Hydrochloric  acid,  when  taken  internally,  increases  the  secretion 
of  pancreatic  juice.  This  augmentation  commences  about  half 
an  hour  after  the  introduction  of  the  acid  into  the  stomach,  and 
continues  for  about  an  hour. 

When  large  quantities  of  acid  are  given,  the  effect  on  the  small 
intestine  is  the  same  whether  the  acid  be  administered  before, 
during,  or  after  meals.  But  when  small  quantities  are  given,  it 
is  best  to  give  them  before  meals.  Small  quantities  of  acid,  which 
per  se  have  no  direct  effect  whatever  on  the  gastric  digestion,  may, 
when  administered  in  this  manner,  exert  an  energetic  influence 
on  digestion  in  the  small  intestine. 

It  has  been  shown  that  hydrochloric  acid  taken  by  the  mouth, 
like  the  natural  product,  prolongs  the  stay  of  the  food  in  the  stomach. 
This  is  due  to  a  periodic  closure  of  the  pylorus  brought  about  by 
the  action  of  the  hydrochloric  acid  on  the  mucous  membrane  of 
the  duodenum,  and  takes  place  whether  the  hydrochloric  acid  is 
given  during  the  meal  or  afterward. 

It  has  been  noted  that  hydrochloric  acid  is  able  also  to  stimulate 
the  secretion  of  bile. 


260  MEDICATION  IN  GASTRIC  DISEASES 

Ingested  hydrochloric  acid  has  a  favorable  influence  on  the 
appetite;  it  is  therefore  a  direct  stomachic.  This  effect  is  due  to 
improvement  in  the  general  nutrition,  and  to  stimulation  of  the 
peripheral  nerve  fibers  which  excite  the  sensation  of  hunger. 

A  number  of  preparations'  containing  hydrochloric  acid  are  at 
our  disposal.    Two  solutions  of  the  acid  are  official : 

1.  Acidum  hydrochloricum — hydrochloric  acid;  100  parts  con- 
tain 31.9  parts  hydrochloric  acid  and  68.1  parts  water. 

2.  Acidum  hydrochloricum  dilutum — diluted  hydrochloric  acid; 
100  parts  contain  10  parts  hydrochloric  acid  and  90  parts  water. 

Hydrochloric  acid  should  be  taken  well  diluted,  through  a  glass 
tube;  otherwise  it  decalcifies  the  tooth  substance  and  irritates 
the  mucous  membrane  of  the  mouth,  pharynx,  and  esophagus. 
For  the  protection  of  healthy  tissue  as  well  as  the  maintenance  of 
comfort  to  the  patient,  suitable  methods  of  drug  administration 
are  demanded;  therefore  the  author  repeats  a  suggestion  with 
regard  to  the  administration  of  hydrochloric  acid  which  his  per- 
sonal experience  has  shown  meets  the  difficulties.  He  has  employed 
this  method  since  1899.1  In  prescribing  the  acid  it  was  at  first 
suggested  that  it  be  taken  in  gelatin  capsules  (Fig.  62).  It  was 
found,  however,  that  the  acid  penetrated  the  capsule  too  quickly. 
After  repeated  trials  it  was  discovered  that  two  capsules  of  differing 
sizes  (the  smaller  one,  containing  the  acid,  encased  in  the  larger  one) 
would  give  sufficient  thickness  to  obviate  quick  penetration — 
would,  in  fact,  retain  the  acid  for  a  long  time  (Fig.  63) .  This  device 
gives  the  patient  ample  time  for  swallowing  and  reduces  to  a  mini- 
mum whatever  annoyance  or  risk  is  involved.  The  double  capsule 
is  easily  constructed.  A  No.  "0"  capsule  will  fit  into  the  body 
of  a  No.  "00"  capsule,  forming  with  it  a  shell  of  double  thickness, 
which,  of  course,  offers  a  twofold  resistance  to  the  action  of  the 
acid  (Fig.  64).  The  lower  edge  of  the  cap  of  the  enclosing  capsule 
is  first  moistened  with  the  tip  of  the  tongue,  so  that  when  it  is  placed 
over  the  body  of  the  capsule  it  becomes  immediately  sealed.  The 
patient  is  instructed  to  use  an  ordinary  dropper  for  placing  the 
hydrochloric  acid  in  £h.e  double  capsule  just  before  taking.  The 
capsule  will  hold  1  Cc.  (15  minims). 

Additions  of  other  medicinal  agents  (except  pepsin)  to  hydro- 
chloric acid  are  not  usual.  To  correct  the  taste,  the  acid  can  be 
given  to  adults  in  tea,  with  or  without  the  addition  of  sugar.  For 
children,  syrup  of  orange  is  a  good  vehicle. 

Acidol. — This  is  a  betain  chlorhydrate,  prepared  from  molasses, 
which  in  watery  solution  splits  up  into  non-toxic  betain  (trimethyl- 
amin  acetic  acid)  and  hydrochloric  acid.  It  is  considered  harm- 
less. Acidol  without  pepsin  is  as  ineffective  for  good  as  hydro- 
chloric acid  without  pepsin.     Combined  with  pepsin  it  has  been 

1  Charles  D.  Aaron:  Simple  Method  of  Administering  Hydrochloric  Acid,  Journal 
of  the  American  Medical  Association,  June  24,  1899. 


ACIDOL 


261 


introduced  to  the  profession  as  acidol-pepsin  tablets.  A  dry 
hydrochloric-acid-protein  powder  has  been  presented  to  the  pro- 
fession under  the  trade  name  oxyntin.  It  may  be  taken  in  the  dry 
form,  in  a  capsule  or  as  a  powder.  Oxyntin  contains  5  per  cent, 
by  weight  of  dilute  hydrochloric  acid,  in  combination  with  albumin, 
the  acid  loosely  bound  to  the  protein.  Six  grams  (100  grains) 
of  the  oxyntin  represent  5  minims  of  dilute  hydrochloric  acid.  It 
is  readily  miscible  with  water,  to  which  it  imparts  but  a  slightly 
acidulous  taste.     Compressed  tablets  containing  0.06  Gm.  (1  grain) 


Fig.  62 


Fig.  63 


Fig.  64 


Single  "00"  gelatin  capsule.      Inner  capsule  in  position.     Double  capsule  closed. 


of  pepsin  with  oxyntin  are  also  manufactured.  These  preparations 
are  not  so  efficacious  as  hydrochloric  acid  and  pepsin  in  liquid  form. 
Fortunately  the  National  Formulary  gives  us  a  number  of  prepa- 
rations containing  both  hydrochloric  acid  and  pepsin.  The  following 
is  especially  recommended: 


Gm.  or  Cc. 


1$ — Acidi  hydrochlorici 2  5 

Pepsini 21  0 

Glycerini 125  0 

Aquae q.  s.  ad  250  0 

Misce. 

Sig. — A  teaspoonful  to  a  tablespoonful  in  a  glass  of  water,  to  be  taken  during 
meals. 


mxi 

5v 
§viij 


262  MEDICATION  IN  GASTRIC  DISEASES 

Pepsin  and  hydrochloric  acid  should  not  be  given  in  an  alcoholic 
menstruum.  Alcohol  is  a  ferment  poison.  Various  drugs  influ- 
ence peptic  digestion.  Iron  is  particularly  detrimental.  While  the 
bitters,  quinine  and  condurango,  are  tonics,  they  should  not  be 
given  with  pepsin,  on  account  of  their  ferment-destroying  property. 
It  is  not  permissible  to  take  pepsin  in  hot  liquids,  since  a  higher 
than  body  temperature  destroys  the  activity  of  this  ferment. 

There  are  a  number  of  other  preparations  intended  to  replace 
pepsin  and  hydrochloric  acid.  One  of  these  is  the  so-called  gasterin, 
or  gastric  juice  of  the  dog.  Pawlow  has  recommended  this  canine 
gastric  juice  as  a  medicinal  agent.  Gasterin,  taken  in  daily  doses 
of  250  to  500  Cc,  has  given  good  results  in  cases  of  subacidity  and 
anacidity.  The  cost  of  the  product  at  present  is  an  obstacle  to 
its  general  employment;  besides,  it  is  somewhat  repulsive.  The 
artificial  mixture  of  hydrochloric  acid  and  pepsin,  fortunately, 
serves  the  same  purpose. 

Another  preparation  intended  to  replace  hydrochloric  acid  and 
pepsin  is  the  so-called  dyspeptine  of  Hepp.  This  is  the  gastric 
juice  of  pigs.  But  it  has  been  found  that  dyspeptine  contains  no 
hydrochloric  acid  whatever,  that  it  does  not  digest  protein,  and 
that  it  is,  therefore,  therapeutically  inactive. 

Pancreatin. — Besides  pepsin,  another  important  digestive  ferment 
is  recognized  by  the  U.  S.  P.,  namely,  pancreatin.  The  official 
pancreatin  possesses  the  property  of  converting  twenty-five  times 
its  own  weight  of  starch  into  substances  soluble  in  water.  Pan- 
creatin should  contain  the  pancreatic  ferments:  trypsin,  which 
digests  proteins;  steapsin,  which  emulsifies  fats;  amylopsin,  which 
converts  starch  into  sugar;  and  a  milk-curdling  ferment. 

Pancreatin  has  marked  digestive  properties;  in  addition  to  its 
action  on  protein  it  converts  all  starches  into  sugar,  emulsifies 
fat,  and  curdles  milk.  It  is  especially  indicated  when  the  stomach 
is  deficient  in  secreting  power.  Often  the  gastroenterologist  finds 
it  necessary  to  treat  the  stomach  as  though  it  were  a  part  of  the 
duodenum.  In  all  cases  of  subacidity  and  achylia,  duodenal  diges- 
tion must  make  up  for  the  deficiency  in  gastric  digestion.  Patients 
who  for  years  have  had  no  severe  or  markedly  distressing  gastric 
symptoms  may  suddenly  be  seized  with  a  diarrhea,  due  to  insuf- 
ficient secretion  of  gastric  juice.  When  the  diarrhea  (gastrogenic) 
once  develops,  the  irritability  of  the  duodenum  should  be  relieved 
as  much  as  possible.  The  condition  may  be  aggravated  by  either 
gastric  hypermotility  or  pyloric  insufficiency.  If  pancreatic  diges- 
tion be  instituted  in  the  stomach,  the  duodenum  will  receive  the 
food  in  a  more  or  less  digested  state,  and  in  this  way  irritation  by 
fermenting  foods  may  be  largely  obviated.  Relieved  of  the  irrita- 
tion, the  intestine,  as  a  rule,  soon  regains  its  lost  tone.  Pancreatic 
preparations  should  always  be  given  with  alkalis,  since  the  alkalis 
in  solution  in  the  stomach  dissolve  mucus.    Pancreatic  prepara- 


38 

gr.  lxvj 

5 

3iij 

5 

Sii 

7 

5ij 

7 

5ij 

7 

5j 

0 

Sviij 

ALKALIS  263 

tions  are  particularly  valuable  in  achylia  gastrica.  Recent  reports 
indicate  that  benefit  is  often  derived  from  the  administration  of 
pancreatin  in  cases  of  alimentary  anaphylaxis. 

Various  preparations  of  the  pancreas  have  been  placed  before  the 
profession  under  trade  names.  Pankreon  is  a  preparation  of  pan- 
creatin containing  10  per  cent,  of  tannic  acid.  It  is  insoluble  in 
acid  media,  but  is  split  up  by  alkalis;  it  therefore  passes  through 
the  stomach  unchanged,  exerting  its  digestive  power  in  the  intes- 
tine. The  best  preparation  for  us  is  the  liquor  pancreaticus  of  the 
National  Formulary,  which  contains  a  small  quantity  of  alcohol  as 
a  preservative.    The  formula  follows: 

Gm.  or  Cc. 

Pancreatin  (U.  S.  P.) 4 

Sodium  bicarbonate 12 

Glycerin 62 

Compound  spirit  of  cardamom  (N.  F.)  .  8 

Alcohol 8 

Purified  talc  (U.  S.  P.) 3 

Water,  a  sufficient  quantity  to  make      .  250 

The  dose  should  be  a  teaspoonful  after  each  meal. 

Papayotin  or  papain,  obtained  from  the  juice  of  the  Carica 
papaya  tree,  is  a  digestant  that  is  frequently  used.  It  is  said  to 
act  in  both  alkaline  and  acid  media. 

Pineapple  juice  possesses  the  power  of  assisting  in  the  digestion 
of  proteins.  Boiling  or  heating,  as  in  the  process  of  canning  pine- 
apples, destroys  the  digestive  power  of  the  juice.  Taken  raw 
or  in  the  natural  state,  this  ferment  is  active  in  either  acid  or 
alkaline  media,  but  not  in  neutral  solutions. 

The  diastatic  ferments  are  suggested  in  those  cases  in  which 
there  is  defective  secretion  of  these  normal  enzymes.  The  ptyalin 
of  the  saliva,  however,  is  rarely  absent.  When  diastase  is  indicated, 
the  best  form  of  this  ferment  seems  to  be  that  preseat  in  pancreatin. 
Vegetable  diastase,  as  found  in  extract  of  malt,  is  sometimes  em- 
ployed. There  are  also  available  many  proprietary  preparations 
of  animal  and  vegetable  diastases.  Diastase  should  always  be 
prescribed  with  alkalis,  or  during  the  meal,  before  free  hydro- 
chloric acid  begins  to  accumulate  in  the  stomach.  The  giving  of 
diastatic  ferments  does  not  remove  the  cause  of  indigestion,  and 
therefore  is  not  resorted  to  as  often  as  formerly,  although  it  will 
often  give  symptomatic  relief. 

Alkalis. — While  the  administration  of  hydrochloric  acid  for 
therapeutic  purposes  dates  from  the  discovery  of  the  fact  that  the 
acidity  of  the  gastric  juice  is  due  to  hydrochloric  acid,  the  adminis- 
tration of  alkalis  has  been  practiced  since  an  early  period  in  the 
history  of  medicine.  It  has  long  been  known  that  alkalis  exert 
a  beneficial  influence  over  certain  diseases  of  the  stomach.  Sodium 
bicarbonate  is  preferred  to  the  potassium  salt  in  disturbances  of 
the  stomach  when  there  is  much  pain  and  a  tendency  to  nausea 


264  MEDICATION  IN  GASTRIC  DISEASES 

accompanied  by  a  gouty  or  rheumatic  diathesis.  Sodium  chlorid 
in  large  doses  is  a  safe  and  easily  available  emetic.  In  the  intestinal 
canal  the  sulphate  and  the  phosphate  of  sodium  act  as  hydragogue 
purgatives.  ■  They  also  act  as  stimulants  to  the  intestinal  glands, 
and  are  being  constantly  absorbed  and  excreted,  reabsorbed  and 
reexcreted,  in  their  course  along  the  bowel. 

Among  the  alkalis  the  Carlsbad  waters  or  those  of  the  Con- 
gress and  Hathorn  Springs  of  Saratoga,  N.  Y.,  and  the  Bedford 
Springs  in  Pennsylvania  come  in  for  consideration.  The  artificial 
Carlsbad  salt  constitutes  an  efficient  substitute  for  the  more  expen- 
sive natural  salt.  The  composition  of  the  artificial  salt  is  as  follows 
( German  Pharmacopoeia) : 

Sodium  sulphate,  dry 44  parts 

Potassium  sulphate 2      " 

Sodium  chlorid 18      " 

Sodium  bicarbonate 36      " 

This  salt  may  be  administered  in  dosesof  one  or  two  dessert- 
spoonfuls in  half  a  pint  of  water,  in  hyperchlorhydria,  hypersecre- 
tion, or  gastric  ulcer,  the  purpose  being  to  neutralize  the  excessive 
secretion  of  hydrochloric  acid.  It  has  been  used  with  greater  or 
less  success  in  gastritis  and  enteritis. 

The  alkalis  are  commonly  divided  into  two  groups — (1)  alkaline 
earths;  (2)  alkaline  carbonates.  Of  the  alkaline  earths,  magne- 
sium oxid  or  calcined  magnesia  is  perhaps  most  important,  as 
well  as  being  the  one  that  is  generally  employed  when  alkalis  are 
indicated.  Magnesium  oxid  is  prepared  by  exposing  magnesium 
carbonate  to  a  dull  red  heat.  It  is  a  white,  very  light  powder, 
sparingly  soluble  in  water.  The  dose  is  0.3  to  2  Gm.  (5  to  30  grains), 
repeated  if  necessary.  In  selecting  an  alkali,  that  which  liberates 
the  least  amount  of  carbon  dioxid  in  the  neutralization  process 
should  be  chosen,  inasmuch  as  the  distention  of  the  weak  muscular 
walls  of  the  stomach  by  gas  is  very  annoying  to  the  patient,  not 
to  say  dangerous  on  account  of  the  pressure  exerted  in  the  region 
of  the  heart.  Of  these  alkalis,  magnesium  oxid  or  the  light  calcined 
magnesia  occupies  the  first  place.  The  chemical  reaction  that  takes 
place  when  magnesium  oxid  is  brought  into  contact  with  free  hydro- 
chloric acid  in  the  stomach  is  expressed  as  follows : 

MgO  +  2HC1   =  MgCl2  +  H20 

Belonging  to  the  alkaline  carbonates  are  sodium  carbonate  and 
sodium  bicarbonate.  Sodium  bicarbonate  combines  with  hydro- 
chloric acid  to  form  sodium  chlorid,  water,  and  carbon  dioxid.  The 
chemical  equation  is  as  follows : 

NaHCOs  +  HC1   =  NaCl  +  H20  +  C02 


BISMUTH  265 

Carbonate  of  sodium  is  used  but  rarely,  owing  to  its  caustic  effecl 
on  the  mucous  membrane. 
The  best  time  for  administration  of  alkalis  in  hyperacidity  is 

from  one-half  to  one  hour  after  meals,  at  the  height  of  digestion. 
The  subjective  symptoms  of  the  patient,  as  gastralgia,  eructation, 
pyrosis,  distention,  constitute  very  good  guides  as  to  the  proper 
time  for  administering  the  alkali.  Owing  to  the  variable  quantity 
of  hydrochloric  acid  found  in  the  stomach  in  the  absence  of  food 
in  cases  of  hypersecretion,  alkalis  should  be  administered  before 
meals  in  such  cases,  in  order  to  insure  salivary  digestion  in  the 
stomach.  Amylolysis  may  be  greatly  assisted  by  the  administration 
of  a  glass  of  Saratoga,  Vichy,  or  sodium  bicarbonate  solution,  4 
(V.  (1  dram)  to  one-half  pint  of  water,  before  meals. 

In  treating  hyperacidity  or  hypersecretion  the  magnesium  salts 
are  to  be  preferred  to  the  other  alkalis,  especially  when  constipa- 
tion and  flatulence  are  pronounced. 

Bismuth. — The  bismuth  preparations  are  derived  from  the 
metal  itself.  Among  the  salts  used  most  commonly  in  the  treat- 
ment of  gastric  affections  are  (1)  bismuth  subnitrate,  (2)  bismuth 
salicylate,  (3)  the  subcarbonate  of  bismuth,  and  (4)  bismuth 
subgallate.  Bismuth  subnitrate  is  a  white,  odorless  powder,  with 
a  high  specific  gravity,  insoluble  in  water,  and  very  faintly  acid. 
The  usual  dose  is  0.3  to  2  Gm.  (5  to  30  grains) .  It  may  be  employed, 
however,  in  much  greater  quantity  for  the  purpose  of  rendering 
the  stomach  or  intestinal  canal  opaque  for  roentgenography, 
though  the  subcarbonate  is  better. 

The  salicylate  of  bismuth  is  prepared  by  the  interaction  of 
bismuth  nitrate  and  sodium  salicylate.  It  is  obtained  as  a  whitish 
and  amorphous  powder  insoluble  in  water,  and  is  administered 
in  doses  ranging  from  0.3  to  2  Gm.  (5  to  30  grains). 

The  subcarbonate  of  bismuth  is  the  result  of  a  chemical  reaction 
between  bismuth  nitrate  and  ammonium  carbonate.  It  also  occurs 
as  a  heavy  white  powder,  insoluble  in  water.  The  dose  is  0.3  to 
2  Gm.  (5  to  30  grains). 

Bismuth  subgallate  is  a  fine,  bright  yellow  powder,  odorless, 
unaffected  by  exposure  to  light.  It  is  recommended  in  gastric 
fermentation  associated  with  diarrhea.  The  dose  is  0.3  to  0.6 
Gm.  (5  to  10  grains). 

The  bismuth  salts  are  all  insoluble  in  the  stomach,  where  they 
exert  a  sedative  and  astringent  action,  either  by  their  effect  upon 
the  nerve  endings  or  the  bloodvessels  in  the  stomach  walls  or  by 
coating  the  mucous  membrane.  They  are  used  more  or  less  exten- 
sively in  the  treatment  of  vomiting  and  pain  due  to  gastric  catarrh 
or  to  irritants  such  as  alcohol,  and  are  important  therapeutic 
agents  in  the  treatment  of  gastric  ulcer  and  gastric  carcinoma. 
These  salts  often  exert  a  favorable  influence  on  so-called  nervous 
or  reflex  vomiting  in  cases  of  pregnancy  or  hysteria  with  true 
gastritis. 


266  MEDICATION  IN  GASTRIC  DISEASES 

Bismuth  salts  were  early  known  to  be  efficacious  in  gastric 
diseases.  They  were  at  one  time  abandoned  on  account  of  the 
frequency  with  which  poisoning  resulted,  due  to  impurities,  for 
the  most  part  from  arsenic.  Since,  however,  by  improved  methods 
of  manufacture  an  absolutely  innocuous  drug  has  been  produced, 
the  bismuth  salts  are  again  widely  employed — both  for  their  ano- 
dyne and  for  their  antacid  effects.  They  ameliorate  or  promptly 
relieve  pains,  cramps,  burnings,  and  sensations  of  weight,  referable 
to  the  stomach.  In  certain  forms  of  gastric  neurosis,  such,  for 
example,  as  nervous  dyspepsia  and  gastric  crises  of  central  origin, 
any  relief  obtained  by  the  administration  of  bismuth  is  at  best 
only  temporary.  The  bismuth  salts,  especially  bismuth  subnitrate, 
are  among  our  best  agents  in  the  treatment  of  gastric  ulcer;  owing 
to  the  soothing  and  astringent  influence  which  they  exert,  the 
lesion  is  in  many  instances  healed.  The  subnitrate  of  bismuth 
seems  to  exert  a  very  marked  influence  upon  such  reflex  symptoms 
as  retching,  vomiting,  and  eructations.  The  drug  has  been  employed 
with  advantage  in  hematemesis. 

It  is  assumed  that  bismuth  subnitrate  liberates  some  of  its 
nascent  nitric  acid,  which  acts  as  an  astringent  and  antiseptic 
on  the  mucous  membrane  of  the  gastro-intestinal  tract.  The 
inefficiency  of  bismuth  subcarbonate  is  supposed  to  be  due  to  the 
absence  of  this  acid.  Bismuth  forms  a  protective  layer  over  gastric 
erosions  and  ulcers,  thus  preventing  existing  lesions  from  coming 
in  direct  contact  with  the  acid  gastric  juice  (see  page  504) . 

Strychnin  and  the  Bitters. — Strychnin  sulphate  is  prepared  from 
mix  vomica.  It  occurs  in  colorless,  odorless,  prismatic  crystals, 
and  has  an  intensely  bitter  taste.  It  is  sparingly  soluble  in  cold 
water,  more  soluble  in  boiling  water.  The  dose  is  0.001  to  0.003 
Gm.  (-^o  to  2V  grain).  Strychnin  and  nux  vomica  possess  the 
properties  of  stomachics.  The  so-called  vegetable  bitters  or 
stomachics  taken  into  the  mouth  stimulate  the  nerves  of  taste, 
producing  thereby  several  reflex  effects  which  are  of  prime  impor- 
tance in  the  promotion  of  digestion.  The  flow  of  saliva  is  increased, 
to  the  advantage  of  diastatic  digestion,  and  the  vessels  and  glands 
of  the  stomach  are  excited  through  the  central  nervous  system. 

In  pyloric  insufficiency  large  amounts  of  strychnin  may  be  given, 
beginning  with  small  doses  and  gradually  increasing  until  0.01  Gm. 
(|  grain)  can  be  given  three  times  a  day.  The  alkaloid  is  useful 
in  the  treatment  of  gastralgia,  in  which  condition  0.001  Gm.  (-^j- 
grain)  of  the  sulphate  may  be  given  hypodermically. 

The  class  of  bitters  includes  also  such  drugs  as  calumba,  quassia, 
cinchona,  gentian,  orange,  and  condurango.  A  distinction  has 
been  drawn  between  simple  bitters  and  true  stomachic  drugs. 
The  former  stimulate  the  appetite,  while  the  latter  (the  complex 
bitters)  stimulate  not  only  the  appetite,  but  the  secretory  and 
motor  functions  of  the  stomach  as  well.    How  the  stimulating 


SILVER  NITRATE  207 

effect  upon  the  appetite  and  digestive  functions  is  brought  aboul 
is  not  definitely  known.  These  remedies  are  indicated,  as  a  rule, 
when  the  appetite  is  poor.  Loss  of  appetite  usually  accompanies 
those  gastric  conditions  in  which  the  secretion  of  gastric  juice  is 
more  or  less  reduced.  When, gastric  secretion  is  normal  the  value 
of  the  bitters  is  questionable. 

Alcohol  is  said  to  act  as  a  stimulant  to  gastric  secretion,  but  it 
has  no  effect  whatever  in  the  production  of  pepsin.  When  alcohol 
is  introduced  by  the  rectum  as  an  ingredient  of  a  rectal  enema  it 
has  the  power  of  stimulating  gastric  secretion.  The  bitter  tonics 
have  been  given  as  tinctures,  and  it  may  be  that  the  alcohol  in 
the  tincture  stimulated  the  secretion  of  gastric  juice  instead  of 
the  bitters  themselves.  According  to  the  investigations  of  Pawlow, 
meat  juices,  raw  meat,  meat  broth,  meat  extractives,  peptones, 
milk,  and  gelatin,  as  well  as  large  quantities  of  water,  have  the 
effect  of  stimulating  gastric  secretion. 

Condurango  bark  was  declared  at  one  time  to  possess  peculiar 
efficacy  in  the  treatment  of  gastric  carcinoma.  Since  1874,  when 
Friedrich  first  called  attention  to  condurango  as  a  therapeutic 
agent  in  carcinoma  of  the  stomach,  it  has  been  widely  administered, 
but  not  with  the  results  claimed  by  Friedrich.  While  this  drug 
has  no  specific  action  on  carcinoma,  it  is  of  some  value  as  a  stom- 
achic.    Condurango  is  best  administered  in  the  form  of  a  decoction. 

]$ — Cort.  condurango 15  parts 

Macerate  for  twelve  hours  with  distilled  water        .  360      " 
Then  evaporate  down  until,  when  strained,  it  equals  180      " 

Sig. — A  tablespoonful  twice  daily. 

Orexin  (phenyldihydrochinazolin  hydrochlorid)  was  introduced 
to  the  profession  by  Penzoldt,  who  claimed  that  it  possessed  the 
property  of  inducing  hunger  and  improving  the  appetite.  Orexin 
has  been  found  to  be  an  irritant  to  the  gastric  mucous  membrane. 
For  the  original  product  a  basic  orexin  w7as  later  substituted,  and 
still  later  the  tannate;  some  of  the  disagreeable  features  of  the 
preparations  have  been  eliminated  by  administering  it  in  capsules. 
The  dose  should  be  followed  by  a  large  draught  of  water.  The 
best  results  are  obtained  from  orexin  when  it  is  administered  in 
a  dose  of  0.3  Gm.  (5  grains)  once  a  day,  preferably  at  ten  o'clock 
in  the  morning,  and  continued  for  about  five  days.  The  special 
indications  for  its  administration  are  gastric  atony  and  acute 
gastritis.  It  is  contra-indicated  in  such  conditions  as  gastric  ulcer, 
hyperacidity,  hypersecretion,  and  other  irritable  conditions  of  the 
stomach. 

Silver  Nitrate. — Silver  nitrate  is  prepared  by  the  interaction  of 
silver  and  nitric  acid;  it  occurs  as  colorless  tubular  rhombic  prisms. 
It  is  soluble  in  half  its  weight  of  water.  Owing  to  the  readiness 
with  which  this  salt  combines  with  chlorids,  all  solutions  should 


268  MEDICATION  IN  GASTRIC  DISEASES 

be  made  with  distilled  water,  and  when  they  are  to  be  preserved 
for  any  length  of  time  they  should  be  kept  in  amber-colored  con- 
tainers. Silver  nitrate  is  slightly  soluble  in  90-per-cent.  alcohol. 
The  incompatibles  of  this  salt  are  alkalis  and  the  carbonates, 
chlorids,  acids  (except  nitric  and  acetic),  potassium  iodid,  solu- 
tions of  arsenic,  and  astringent  infusions.  In  the  stomach  nitrate 
of  silver  is  decomposed  by  hydrochloric  acid  and  mucus,  and  can- 
not act  as  an  irritant  upon  the  mucous  membrane  unless  adminis- 
tered in  toxic  doses.  Baibakoff  found  that  silver  nitrate  has.  the 
property  of  increasing  the  acidity  of  the  gastric  juice,  especially 
in  cases  in  which  there  was  hyperacidity  before  the  use  of  the  drug. 
According  to  this,  silver  nitrate  is  contra-indicated  in  hyperacidity, 
hypersecretion,  and  peptic  ulcer.  The  silver  salts  are  indicated 
rather  in  the  treatment  of  the  subacid  conditions  which  usually 
accompany  chronic  gastric  catarrh.  In  chronic  gastritis  the  power 
to  digest  proteins  is  somewhat  diminished,  so  the  effect  of  the 
silver  salts  by  way  of  increasing  gastric  secretion  meets  the  thera- 
peutic requirements  in  this  class  of  cases.  Silver  nitrate  has  been 
found  to  have  an  anticatarrhal  action  on  the  gastric  mucosa  in 
gastritis.  The  drug  exerts  an  antifermentative  influence  also, 
inhibiting  the  development  of  gases,  belching,  and  eructations. 
Experiments  have  shown  that  silver  nitrate  possesses  the  power  of 
increasing  gastric  motility.  The  test  breakfast  has  been  found  to 
leave  the  stomach  within  a  shorter  interval  when  nitrate  of  silver 
is  administered  than  when  no  medication  is  employed. 

The  dosage  of  nitrate  of  silver  should  be  so  regulated  as  to  meet 
the  requirements  of  the  individual  case  or  particular  stage  in  the 
progress  of  the  disease.  Large  doses,  0.03  Gm.  (|  grain),  adminis- 
tered three  times  a  day,  increase  the  flow  of  gastric  juice;  usually, 
however,  this  effect  may  be  accomplished  with  doses  as  small  as 
0.002  Gm.  (-j-q  grain)  given  three  times  a  day.  The  physician 
administering  nitrate  of  silver  should  be  on  his  guard  against 
argyria. 

Gastric  Sedatives. — Among  gastric  sedatives  are  drugs  which 
reduce  the  excitability  of  the  vomiting  center.  In  this  class  are 
amyl  nitrite,  nitroglycerin,  opium,  chloral  hydrate,  the  bromids, 
and  dilute  hydrocyanic  acid.  As  sedatives  to  the  afferent  nerves 
of  the  stomach  may  be  mentioned  hot  water,  ice,  dilute  hydrochloric 
acid,  carbon  dioxid,  bismuth,  dilute  alkalis,  opium,  ipecac,  and 
calomel  in  small  doses. 

Amyl  Nitrite. — Amyl  nitrite  occurs  in  the  liquid  form,  being 
chiefly  an  isoamyl  nitrite.  It  is  an  ethereal  liquid  of  a  yellowish 
color,  fragrant  odor,  and  faintly  acid  reaction,  readily  soluble  in 
90-per-cent.  alcohol,  but  almost  insoluble  in  water.  It  is  adminis- 
tered as  a  vaso-dilator  in  circulatory  disturbances,  in  the  form 
of  vapor  (inhalation)  from  an  amyl  nitrite  pearl,  or  thin  glass 
shell,  which  is  crushed  by  the  patient  in  a  handkerchief.    The 


GASTRIC  SEDATIVES  209 

dose  internally  as  a  gastric  sedative  is  one-half  to  one  minim  in 
rectified  spirit. 

Nitroglycerin. — Nitroglycerin,  trinitrin,  or  glonoin,  is  a  colorless 
oily  liquid  with  a  sweetish  taste,  very  slightly  soluble  in  water, 
but  freely  soluble  in  fats,  oil,  alcohol,  or  ether.  Its  uses  are  similar 
to  those  of  amyl  nitrite.     The  dose  is  one-half  minim  to  two  minims. 

Chloral  Hydrate. — Chloral  hydrate  is  prepared  from  chloral  by 
the  addition  of  water.  The  drug  occurs  in  colorless  crystals,  soluble 
in  an  equal  quantity  of  distilled  water,  90-per-cent.  alcohol,  or 
ether.  It  is  likewise  soluble  in  four  parts  of  chloroform.  The  dose 
is  0.3  to  1.2  Gm.  (5  to  20  grains)  in  solution.  While  the  chief  use 
of  chloral  hydrate  is  as  a  hypnotic,  it  has  been  found  valuable  for 
allaying  vomiting  or  irritability  of  the  stomach,  owing  to  its  sedative 
effect  on  the  vomiting  center. 

Bromids. — The  bromids  are  gastric  sedatives,  inasmuch  as  they 
act  as  depressants  not  only  to  the  brain  and  spinal  cord  but  to  the 
peripheral  nerves. 

Dilute  Hydrocyanic  Acid. — Dilute  hydrocyanic  acid  is  an  aqueous 
solution,  a  colorless  liquid,  faintly  acid  in  reaction,  with  a  specific 
gravity  of  0.997.  It  is  incompatible  with  the  salts  of  iron,  copper, 
and  silver.  Its  chief  use  is  as  a  sedative  to  the  nerves  of  the  stomach. 
It  is  employed  to  relieve  gastric  pain  and  allay  vomiting  in  ulcer 
and  in  reflex  and  other  nervous  disorders  of  the  stomach.  In  all 
probability  the  greater  share  of  the  influence  exerted  by  this  drug 
on  the  conditions  named  is  exerted  by  way  of  the  medulla  oblongata. 
Hydrocyanic  acid  is  speedily  disseminated  throughout  the  tissues, 
selecting  for  its  action  the  nerve  structures.  The  drug  also  acts 
as  a  cardiac  sedative,  especially  in  heart  conditions  resulting  from 
derangement  of  the  gastric  function.  The  dose  of  the  dilute  acid 
is  0.06  to  0.2  Cc.  (1  to  3  minims). 

Cannabis  Indica. — Cannabis  indica  (Indian  hemp)  is  prepared 
from  the  dry  tops  of  Cannabis  sativa  grown  in  India.  Among 
the  preparations  prescribed  are  the  alcoholic  extract,  dose  0.015 
to  0.06  Gm.  (I  to  1  grain),  and  the  tincture,  dose  0.3  to  1  Cc. 
(5  to  15  minims).  The  drug  may  be  used  internally  as  a  cor- 
rective of  griping  purgatives  such  as  podophyllin  and  colocynth. 
Large  doses  produce  a  peculiar  species  of  intoxication,  involving 
disordered  consciousness  of  personality,  locality,  and  time.  The 
local  effect  upon  the  stomach  is  that  of  a  sedative.  The  drug  is 
said  to  provoke  a  ravenous  appetite  at  times.  American  cannabis, 
from  Cannabis  sativa  grown  in  America,  has  the  same  effect  as  the 
Indian  drug,  and  its  preparations  are  administered  in  the  same  dose. 

Cocain  Hydrochlorid. — Cocain  hydrochlorid,  the  salt  of  cocain 
most  frequently  employed  for  medicinal  purposes,  is  obtained 
from  the  leaves  of  the  Erythroxylon  coca.  The  salt  is  in  the  form 
of  fine  crystals  that  are  soluble  in  half  their  weight  of  cold  water 
and  in  four  parts  of  alcohol.     With  water,  cocain  hydrochlorid 


270  MEDICATION  IN  GASTRIC  DISEASES 

forms  a  colorless  solution,  neutral  in  reaction;  the  solution  has 
a  bitter  taste,  causing  tingling  of  the  tongue,  soon  followed  by 
numbness.  The  dose  is  0.01  to  0.03  Gm.  (^  to  |  grain).  Cocain 
hydrochlorid  as  a  local  anesthetic  is  well  known.  The  effect  of 
the  drug  is  confined  to  mucous  membrane  and  the  deeper  tissues; 
the  skin  is  peculiarly  exempt.  Cocain  hydrochlorid  may  be  used 
as  a  local  sedative  in  all  irritations  of  the  stomach.  In  vomiting 
accompanied  by  pain  it  has  been  found  extremely  valuable. 

Apothesine,  a  recent  discovery  is  administered  by  mouth  in  the 
treatment  of  nausea  and  gastric  pain;  it  acts  as  a  local  anesthetic 
in  doses  of  0.015  to  0.03  Gm.  (J  to  |  grain). 

Gastric  Anodynes. — Chloroform. — Five  or  six  drops  of  chloroform 
on  sugar  or  ice  is  useful  in  the  treatment  of  selected  cases  of  gas- 
tralgia.  Chloroform  has  been  found  not  only  to  afford  temporary 
relief  from  pain,  but  to  arrest  the  course  of  the  general  disease. 
Chloroform  water  (1  :  150)  can  be  administered  every  hour  in 
tablespoonful  doses.  Its  action  is  that  of  a  local  sedative  and 
antiseptic.  Small  doses  of  chloroform  have  been  found  capable  of 
arresting  vomiting  in  gastric  ulcer.  Chloroform  may  be  adminis- 
tered conveniently  with  bismuth. 

Orthoform-new. — Orthoform  is  a  methylaminoparaoxybenzoate. 
It  is  a  fine,  whitish,  odorless,  tasteless  powder,  sparingly  soluble  in 
water,  and  is  credited  with  possessing  local  anesthetic  and  anti- 
septic properties.  It  is  said  to  be  non-toxic.  Its  analgesic  action 
is  manifest  only  when  the  drug  comes  into  direct  contact  with  the 
exposed  ends  of  nerves.  Orthoform  as  a  local  anesthetic  resembles 
cocain  somewhat,  but  differs  from  the  latter  in  the  fact  that, 
owing  to  its  insolubility,  it  does  not  penetrate  the  tissues.  It  has 
been  prescribed  extensively,  to  be  taken  by  the  mouth,  for  the 
relief  of  the  pain  of  gastric  ulcer;  and  the  fact  that  it  does  not 
get  below  the  surface,  and  therefore  cannot  relieve  any  but  super- 
ficial pain,  makes  it  useful  as  a  diagnostic  agent.  When  relief  of 
gastric  pain  follows  its  internal  administration,  this  fact  is  con- 
sidered an  indication  of  the  presence  of  ulcer  of  the  stomach.  The 
internal  dose  is  0.5  to  1  Gm.  (7  to  15  grains)  in  the  form  of  a  mixture. 

Anesihesin. — Anesthesin  is  ethyl-paraminobenzoate,  or  the  ethyl 
ester  of  paraminobenzoic  acid.  It  occurs  as  a  white,  crystalline, 
odorless  and  tasteless  powder,  which  produces  a  sensation  of  numb- 
ness when  placed  on  the  tongue.  It  is  with  difficulty  soluble  in 
hot  water,  and  almost  insoluble  in  cold.  In  six  parts  of  alcohol  or 
ether  it  should  form  a  clear,  colorless,  neutral  solution.  It  may 
be  sterilized  in  oil  solutions  without  undergoing  decomposition. 
Anesthesin  was  introduced  to  the  profession  as  a  local  anesthetic 
resembling  orthoform  in  its  action.  It  does  not  penetrate  mucous 
membranes,  and,  being  insoluble  in  water,  cannot  be  administered 
hypodermically.  It  has  been  prescribed  for  the  relief  of  pain  in 
gastric  ulcer  and  gastric  carcinoma  and  in  various  forms  of  gastralgia. 
The  dose  is  0.3  to  0.5  Gm.  (5  to  7  grains)  in  capsule. 


DRUG'S   USED   1  SCIDF.ST M.I.Y  271 

Drugs  Used  Incidentally  in  Gastric  Disorders. — Atropin,  PUocarpin, 
a  ml  Nicotin. — ^Ye  have  a  number  of  drugs  which  are  used  largely 
for  their  indirect  effect  in  the  treatment  of  gastric  condition-. 
Atropin,  the  alkaloid  of  belladonna  leaves  or  root,  performs  an 
important  role  when  there  is  an  excess  of  secretion.  Belladonna 
produces  a  slightly  anodyne  effect  when  taken  into  the  stomach, 
and  has  been  used  to  relieve  some  forms  of  gastralgia.  It  has 
been  fomid  especially  valuable  in  cases  of  vagotonia.  The  hypo- 
dermic use  of  atropin  in  hyperacid  conditions  was  first  recom- 
mended by  Riegel.  Owing  to  the  fact  that  in  order  to  obtain  inhibi- 
tion of  gastric  secretion  the  dose  of  the  drug  must  be  somewhat  large, 
there  is  more  or  less  danger  of  poisoning  from  the  use  of  it.  Regard- 
ing the  action  of  atropin,  pilocarpin,  and  nicotin,  it  may  be  said 
that  atropin  in  small  doses  injected  directly  into  the  blood  or  into 
the  salivary  gland  duct  prevents  the  action  of  the  chorda  tympani, 
thus  producing  inhibition  of  the  salivary  secretion;  it  apparently 
paralyzes  the  endings  of  the  cerebral  fibers  in  the  glands.  Pilo- 
carpin is  mentioned,  owing  to  the  fact  that  its  effect  upon  the  secre- 
tory mechanism  is  exactly  opposite  to  that  of  atropin.  From  the 
minutest  doses  of  pilocarpin  we  get  a  continuous  secretion  of 
saliva;  it  is  supposed  that  the  drug  stimulates  the  endings  of  the 
secretory  fibers  of  the  salivary  glands.  Pilocarpin  and  atropin 
are  to  a  certain  extent  physiologic  antagonists.  Nicotin  in  its 
effect  upon  salivary  secretion  differs  from  both  of  the  other  two; 
it  inhibits  the  action  of  the  secretory  nerves  by  paralyzing  the 
connections  between  the  nerve  fibers  and  the  ganglion  cells.  These 
drugs  are,  valuable  in  the  treatment  of  the  neuroses  associated 
with  "vagotonia"  and  "sympathicotonia"  (see  page  388). 

Eumydrin. — Eumydrin  (atropin  methyl  nitrate)  is  the  nitrate 
of  methylated  atropin.  It  is  similar  in  its  action  to  atropin,  but 
reputedly  much  less  toxic,  and  may  therefore  be  given  in  larger 
doses.  According  to  Schoenheim,  eiunydrin  is  fifty  times  less 
poisonous  than  atropin  sulphate,  and,  owing  to  the  introduction 
of  the  methyl  group,  is  entirely  devoid  of  any  action  upon  the 
central  nervous  system.  It  is  therefore  able  to  act  more  powerfully 
upon  the  peripheral  nerve  endings  and  secretory  glands.  The  dose 
of  eiunydrin  is  0.001  to  0.003  Gm.  (^  to  -^  grain). 

Epinephrin. — Epinephrin  (adrenalin)  is  a  substance  obtained  from 
the  suprarenal  glands  of  sheep  or  other  animals.  It  is  an  alkaloidal 
product,  slightly  alkaline  in  reaction.  It  is  a  powerful  styptic, 
exercising  a  constricting  effect  on  the  bloodvessels,  with  a  conse- 
quent raising  of  blood-pressure.  Hypodermically  the  dose  is  0.06 
to  1  Cc.  (1  to  15  minims)  of  the  1:1000  solution  diluted  with 
sterile  water.  Epinephrin  has  been  employed  to  arrest  gastric 
hemorrhage,  being  administered  by  mouth  in  doses  of  20  to  30 
drops  of  the  1:1000  solution  three  or  four  times  a  day.  No 
untoward  results  seem  to  follow  the  prolonged  administration  of 
the  drug  in  these  cases. 


272  MEDICATION  IN  GASTRIC  DISEASES 

Antiseptics. — Among  the  drugs  used  as  antiseptics  for  the  stomach 
we  have  resorcinol,  phenol,  and  the  salicylates. 

Resorcinol. — Resorcinol  is  a  phenol  derivative  which  occurs  in 
white,  lustrous  crystals  with  a  sweetish,  pungent  taste.  It  is  soluble 
in  equal  parts  of  water,  twenty  parts  of  olive  oil,  or  half  its  weight 
of  alcohol.  Resorcinol  is  essentially  an  antiseptic,  disinfectant, 
analgesic,  and  hemostatic,  being  non-irritating  in  solutions  of  2 
to  10  per  cent.  The  dose  is  0.12  to  0.25  Gm.  (2  to  4  grains)  after 
meals,  in  pill  or  capsule. 

Phenol. — Phenol,  or  carbolic  acid,  is  obtained  by  the  fractional 
distillation  of  coal  tar.  It  occurs  in  colorless  hygroscopic  crystals, 
soluble  in  12  parts  water,  freely  soluble  in  glycerin.  Phenol  is 
an  excellent  antizymotic.  The  manner  in  which  it  performs  the 
function  of  antizymosis  is  not  well  understood.  In  vomiting  due 
to  a  neurosis  or  gastric  irritation  0.03  to  0.12  Cc.  (|  to  2  minims), 
well  diluted,  depresses  the  sensory  nerves  of  the  stomach. 

Salicylates. — As  antizymotics,  the  salicylates,  particularly  sodium 
salicylate,  retard  the  fermentation  of  milk  in  the  stomach  and 
promote  its  digestion.  Given  to  patients  with  gastro-intestinal 
disease,  they  destroy  the  fetid  odor  of  the  breath  as  well  as  that  of 
the  feces.  The  drug  should,  as  a  rule,  follow. the  administration  of 
a  purgative  in  order  that  the  colon  may  be  kept  free,  inasmuch  as 
gastric  disturbances  are  often  caused  by  fecal  impaction.  Acetyl- 
salicylic  acid  will  allay  irritation,  mitigate  pain,  and  reduce  con- 
gestion of  the  gastric  mucosa.  It  must  be  given  in  small  doses, 
0.5  Gm.  (7|  grains)  with  meals.  The  salicylates  are  valuable  for 
controlling  certain  reflex  symptoms  of  gastric  origin,  such  as  flush- 
ing of  the  face,  congestive  headache,  vertigo,  and  insomnia  of 
gastric  origin.  Salicylic  acid  is  said  to  reduce  gastric  secretion  by 
about  one-half,  while  it  increases  biliary  secretion  to  the  extent  of 
20  to  80  per  cent. 

Iodin. — Tincture  of  iodin  is  occasionally  employed  in  the  treat- 
ment of  gastric  ulcer,  both  for  its  anodyne  effect  and  as  a  stimulus 
to  healing.  It  is  likewise  a  valuable  antiseptic.  Administered  in 
drop  doses,  freely  diluted,  it  has  proved  efficacious  in  some  cases  of 
vomiting  of  pregnancy  that  had  resisted  other  measures. 

Hydrogen  Peroxid. — Hydrogen  peroxid  is  prepared  by  the 
interaction  of  water,  barium  peroxid,  and  a  dilute  mineral  acid, 
at  a  temperature  below  10°  C.  It  is  a  colorless,  odorless  liquid, 
with  a  slightly  acrid  taste.  Heat  decomposes  it  into  water  and 
oxygen.  Aqua  hydrogenii  dioxidi,  U.  S.  P.,  should  contain  3  per 
cent,  of  absolute  hydrogen  dioxid.  It  is  a  powerful  oxidizing 
agent,  possessing  marked  disinfectant  properties.  Rinsing  the 
mouth  with  a  1-per-cent.  solution  of  hydrogen  peroxid  has  been 
found  to  cause  marked  increase  in  the  secretion  of  saliva.  Inter- 
nally administered,  hydrogen  peroxid  has  been  found  to  reduce 
the  total  acidity  of  the  gastric  secretion,  especially  the  proportion  of 


EMOLLIENTS  273 

free  hydrochloric  acid.  When  the  purpose  is  to  reduce  the  acidity 
within  normal  hounds,  hydrogen  dioxid  should  be  given  like  a 
mineral  water  on  the  fasting  stomach  in  the  morning  in  the  pro- 
portion of  1  to  3  Cc.  in  200  to  300  Cc.  of  water.  In  hyperacidity 
and  acid  fermentation  hydrogen  peroxid  may  be  used  in  0.25  to 
O.Sjper  cent,  solution  for  washing  out  the  stomach.  The  drug  is 
useful  in  the  treatment  of  hyperacidity,  hyperchlorhydria,  ulcer, 
and  spasm  of  the  pylorus. 

Magnesium  peroxid  is  placed  on  the  market  under  the  trade 
name  of  magnesium  perhydrol.  In  the  acid  gastric  juice  mag- 
nesiiun  peroxid  is  converted  into  magnesium  salts  and  peroxid 
of  hydrogen.  Upon  this  latter  substance  its  therapeutic  value 
depends.  It  can  be  administered  in  tablet  form,  0.5  Gm.  (J\  grains) 
containing  25  per  cent,  of  magnesium  peroxid. 

Emollients.— -Olive  Oil. — Cohnheim  wTas  among  the  first  to  draw 
attention  to  the  value  of  oil  in  the  treatment  of  gastric  affections. 
He  mentions  a  case  of  probable  traumatic  ulcer  of  the  stomach  so 
painful  that  the  patient  avoided  food,  in  which  complete  relief  of 
the  distressing  symptoms  followed  the  administration  of  a  wineglass 
of  olive  oil  before  meals.  Amelioration  of  symptoms  by  the  use  of 
olive  oil  has  been  reported  even  in  carcinoma  of  the  stomach;  satis- 
factory residts  are  frequently  obtained  in  the  treatment  of  benign 
pyloric  stenosis.  Olive  oil  decreases  gastric  acidity  and  retards  the 
evacuation  of  the  stomach.  This  oil  is  useful  in  the  treatment  of 
spasm,  pain,  and  hyperacidity,  as  well  as  for  increasing  the  nutri- 
tion of  the  body.  Permanent  cures  have  been  reported  in  cases  of 
spastic  stenosis,  fissures  and  erosions  of  the  pylorus,  ulcer,  and 
gastritis  (see  pages  481  and  484). 

Olive  oil  is  laxative  and  nutritious.  During  its  use  patients  may 
pass  lumps  of  white  fat  composed  of  undigested  palmitin.  In  doses 
of  one-half  to  three  oimces  it  has  been  known  to  relieve  obstructive 
jaundice.  It  is  a  valuable  remedy  in  hepatic  colic.  In  gallstone 
disease  large  doses  (from  three  to  five  ounces)  of  olive  oil  will 
frequently  mitigate  pain,  though  not,  as  supposed  by  some,  bring 
about  a  disintegration  of  the  concretions. 


18 


CHAPTER  XIV. 

MEDICATION  IN  INTESTINAL  DISEASES. 

The  medicinal  treatment  of  diseases  of  the  intestine  is  based 
upon  the  same  principles  as  the  dietetic  treatment.  It  is  necessary 
in  some  cases  to  produce  constipating  effects  and  in  other  cases 
to  induce  purgation.  Generally  speaking,  medication  is  only  to  be 
employed  when  dietetic  measures  are  found  to  be  inadequate. 

INTESTINAL  SEDATIVES. 

The  sedatives  exert  their  characteristic  effects: 

1.  By  putting  the  intestine  at  rest  through  nervous  channels 
(narcotics). 

2.  By  their  direct  influence  on  the  intestinal  mucous  membrane 
affected  by  hypersecretion  or  hyperemia  (astringents  and  protec- 
tives). 

3.  By  inhibiting  the  putrefactive  or  fermentative  processes  of 
the  intestine,  thus  producing  indirectly  a  beneficial  effect  on  the 
mucous  membrane  (antiseptics  and  antifermentatives). 

Narcotics. — The  preparations  of  opium  are  the  sovereign  reme- 
dies for  alleviating  intestinal  pains  and  the  profuse  acute  diarrhea 
that  accompanies  them.  Opium  contains  a  variety  of  vegetable 
substances,  with  a  large  number  of  alkaloids  combined  with  meconic 
acid.  The  most  important  of  these  alkaloids  is  morphin.  Medici- 
nally only  such  specimens  of  opium  should  be  used  as  are  rich  in 
morphin  (at  least  10  per  cent.)  and  poor  in  the  other  alkaloids 
(4  to  5  per  cent.).  The  effect  of  small  doses  of  opium  is  there- 
fore qualitatively  nearly  identical  with  that  of  morphin.  Opium 
is  preferred  to  morphin  in  intestinal  diseases  because  it  is  slowly 
absorbed,  and  the  effects  are  therefore  much  milder  and  more 
gradual,  less  poisonous,  and  more  lasting.  The  slow  absorption 
of  opium  is  due  to  the  fact  that  it  contains  a  large  amount  of  resinoid 
colloidal  ingredients,  in  which  the  alkaloids  seem  to  be  embedded, 
and  which  are  slowly  dissolved  in  the  intestine.  The  drug  paralyzes 
the  peristaltic  movements  of  the  intestine.  The  effect  of  opium 
on  peristalsis  is  twofold:  by  stimulation  of  the  inhibitory  centers 
through  the  splanchnic  nerves,  and  by  direct  action  on  the  nerves 
and  muscular  structures  in  the  wall  of  the  intestine  itself.  This 
desirable  effect  is  not  to  be  obtained  by  means  of  any  other  drug. 
If  there  is  pain  in  the  abdomen,  opium  is  a  powerful  anodyne;  the 


NARCOTICS  275 

intestine  is  nearly  always  quieted  promptly,  and  the  pains  disappear. 
We  may  say,  therefore,  that  opium  is  indicated  in  abnormally 
strong  peristalsis  accompanied  by  diarrhea,  and  to  relieve  enteralgias 
and  inflammatory  processes.  It  is  most  frequently  used  to  modify 
acute  diarrhea,  particularly  in  eases  of  acute  intestinal  or  gastro- 
intestinal catarrh.  The  intestine,  however,  should  first  be  thor- 
oughly cleaned  out,  so  that  the  irritating  material  that  caused  the 
catarrh  may  be  entirely  eliminated.  After  this  evacuation,  either 
resulting  spontaneously  or  by  the  aid  of  calomel  or  castor  oil,  is 
the  time  for  the  administration  of  opium.  At  this  period  the  feces 
are  entirely  liquid  and  the  bad  odors  absent.  Tenesmus  occurring 
simultaneously  with  the  diarrhea  is  a  further  indication  for  opium. 
The  opium  should  be  given  freely  and  energetically  at  first,  but  only 
for  a  short  time.    Usually  one  day  of  it  is  sufficient. 

Opium  is  contra-indicated  in  chronic  diarrhea,  chronic  catarrh, 
ulcers,  gastrogenic  and  nervous  diarrheas.  In  such  cases  it  would 
probably  keep  the  bowel  quiet  for  a  short  time,  allowing  the  reten- 
tion of  decomposing  and  fermenting  fecal  masses.  Opium  is  further- 
more contra-indicated  in  old  age  and  childhood,  as  during  these 
periods  there  often  exists  great  hypersensitiveness  toward  even  small 
doses  of  this  drug. 

Opium  may  be  administered  in  the  form  of  extractum  opii,  con- 
taining 20  per  cent,  of  crystallized  morphin,  a  dry,  reddish-brown 
extract,  which  may  be  prescribed  in  doses  of  0.03  to  0.06  Gm.  (|  to 
1  grain)  as  a  powder  or  pill  or  in  a  mixture.  Tinctura  opii  (lauda- 
num) is  frequently  used;  it  is  an  alcoholic  solution  of  opium  which 
may  be  given  in  doses  of  0.2  to  1.2  Cc.  (3  to  20  minims).  Tincture 
opii  camphoratas  (paregoric)  is  a  popular  remedy  in  doses  of  4  to  8 
Cc.  (1  to  2  drams).  Sometimes  Dover's  powder  (pin1  vis  ipecacu- 
anha? et  opii)  may  be  given;  it  is  prescribed  in  doses  of  0.25  to  1.5 
Gm.  (4  to  25  grains).  If  necessary,  extractum  opii  may  be  given  in 
the  form  of  suppositories  containing  0.03  Gm.  (f  grain),  but  their 
action  is  slower. 

A  preparation  of  opium  under  the  trade  name  pantopon  (pan- 
topinum  hydrochloridum)  is  said  to  contain  all  the  alkaloids  of 
opium  in  combination  with  hydrochloric  acid,  which  renders  it 
easily  soluble.  It  was  prepared  on  the  suggestion  of  S?hli,  with 
reference  to  the  fact,  verified  by  clinical  experience,  that  the  entire 
alkaloids  of  the  poppy  plant,  contained  in  opium,  have  a  more 
marked  sedative,  hypnotic  and  constipating  effect  than  morphin 
alone,  while  their  disagreeable  after-effects  are  much  less  than  those 
of  morphin.  Pantopon  is  given  internally  in  doses  of  0.005  to  0.02 
Gm.  (TV  to  \  grain).  Subcutaneously  injected,  in  2-per-cent.  solu- 
tion, it  produces  no  irritation  whatever. 

Papaverin  is  a  white  alkaloid  from  opium  which  has  a  marked 
antispasmodic  effect  in  doses  ot  0.008  to  0.016  Gm.  (f  to  i  grain). 
The  papaverin  group  produces  relaxation  in  tonus  and  inhibition 


276  MEDICATION  IN  INTESTINAL  DISEASES 

of  peristaltic  movements  of  all  smooth  muscle  organs.  This  action 
is  the  direct  opposite  of  that  of  morphin,  which  tends  to  raise  smooth 
muscle  tonus  and  stimulate  its  contractions.  Macht  discovered 
that  the  inhibitory  and  tonus-lowering  properties  of  papaverin 
were  due  to  the  benzyl  grouping  of  the  papaverin  molecule.  By 
further  investigation  he  found  that  benzyl  benzoate  produced  the 
papaverin  effect  without  being  itself  very  toxic.  Benzyl  benzoate 
is  an  ester  of  benzvl  alcohol  and  benzoic  acid.  It  is  a  non-poisonous, 
clear,  colorless  liquid,  of  neutral  reaction.  It  relaxes  tonus  or 
spasm  and  inhibits  the  contractions  of  all  smooth  muscle  organs. 
It  is  a  valuable  medicament  in  all  cases  of  excessive  intestinal 
peristalsis,  and  in  spasm  of  the  esophagus,  stomach,  intestine,  gall 
bladder  or  biliary  ducts.  It  is  prescribed  in  cardiospasm,  pyloro- 
spasm,  diarrhea,  dysentery,  spastic  constipation,  enteralgias, 
enteritis  membranacea  and  in  intestinal  and  biliary  colic.  The 
usual  dose  of  the  solution  is  1  to  2  Cc.  (15  to  30  minims)  three  or 
more  times  daily,  in  water  or  milk. 

Uzara  is  the  native  name  of  a  semishrub  indigenous  to  the 
African  sea  regions.  It  has  not  as  yet  received  a  botanical  name, 
but  probably  belongs  to  the  family  of  the  Asclepiadse.  Its  medic- 
inal properties  reside  in  the  roots.  It  is  used  in  both  acute  and 
chronic  forms  of  diarrhea.  The  tincture  of  uzara  is  a  2-per-cent. 
solution;  dose,  1  Cc.  (15  minims)  six  times  daily.  The  tablets  of 
uzara  contain  0.005  Gm.  (y-g  grain) ;  dose,  three  to  six  tablets  a  day. 
A  combination  of  uzara  and  tannin  is  marketed  under  the  trade 
name  of  uzaratin.  All  these  preparations  must  be  used  with  caution 
on  account  of  the  poisonous  properties  of  uzara. 

Astringents  and  Protectives. — Medicinal  substances  capable  of 
exerting  a  favorable  influence  on  the  intestinal  mucous  membrane 
while  it  is  in  a  state  of  inflammation  attain  this  end  either  by 
their  astringent  effect  or  by  depositing  a  protective  covering  upon 
the  mucous  membrane  which  acts  as  a  local  sedative.  Some  drugs 
produce  both  these  effects  simultaneously;  others  exert  in  addition 
a  disinfectant  action  on  the  contents  of  the  intestine. 

(a)  Astringe?ite. — The  astringents  possess  the  power  of  precipi- 
tating protein  bodies,  gelatin  and  mucus,  and  thereby  forming 
albuminates.  They  affect  all  tissues  similarly,  but  have  in  addi- 
tion a  special  effect  on  mucous  membranes,  in  contact  with  which 
they  deposit  new  solid  particles  (newly  formed  albuminous  com- 
pounds) in  the  tissue  interspaces.  This  results  in  a  contraction 
of  the  tissues.  A  sort  of  anemia  is  produced  in  the  tissues,  which 
thus  become  poor  soil  for  bacterial  growth.  The  mucous  secretion 
diminishes,  and  the  membrane  soon  loses  its  hyperemia;  in  short, 
the  inflammatory  processes  decline.  The  astringent  action,  how- 
ever, should  be  confined  to  the  surface,  to  form  a  thin  super- 
ficial coating,  for  if  it  should  happen  to  penetrate  more  deeply 
the  tissues  might  be  destroyed.    It  is  therefore  possible  that  sub- 


ASTRINGENTS  AND  PROTECTIVES  277 

stances  used  in  small  quantities  or  in  weak  solutions,  with  an 
astringent  effect  only,  might  prove  caustic  if  used  in  greater  con- 
centration. 

The  astringent  best  known  and  most  extensively  used  is  tannic 
acid.  Pure  tannic  acid  is  not  adapted  to  the  treatment  of  the 
diseased  mucous  membrane  of  the  intestine,  because  it  rapidly 
unites  with  protein  in  the  stomach,  entering  the  intestine  in  a 
combined  and  inactive  form.  In  the  alkaline  intestinal  secretions 
these  albuminates  are  converted  into  alkalitannates,  which  are 
capable  of  producing  only  insignificant  astringent  effects.  More- 
over, the  effect  of  pure  tannic  acid  on  the  mucous  membrane  of 
the  stomach  is  caustic  and  may  result  seriously.  For  this  reason 
the  compounds  are  used  instead  of  pure  tannic  acid. 

The  tamiin-albumin  compounds  are  insoluble  in  acid  media,  and 
are  therefore  not  acted  upon  by  the  acid  gastric  juice,  but  in  the 
alkaline  intestinal  secretions  a  sufficient  amount  of  nascent  tannin 
is  liberated. 

Tannalbin,  a  compound  of  this  class,  is  prepared  by  heating 
tannin  with  albumin;  it  contains  50  per  cent,  of  tannin.  The 
beneficial  effect  of  this  compound  in  diarrhea  is  recognized.  The 
dose  for  adults  is  1  Gm.  (15  grains),  for  children  0.5  Gm.  (7  grains), 
several  times  daily. 

Tannocol  (tanningelatin),  honthin  (keratinized  albumm-tannate) 
and  glutanol  (a  compound  of  aleuronat  and  tannin)  are  adminis- 
tered in  similar  doses. 

A  preparation  of  more  recent  introduction  is  tannyl,  a  compoimd 
of  oxychlorcasein  with  tannic  acid.  This  is  a  brownish-yellow 
powder,  odorless  and  tasteless,  insoluble  in  water  and  acid  gastric 
juice,  having  well-marked  astringent  and  antiseptic  properties. 
Tannyl  is  valuable  in  catarrh  of  both  the  large  and  the  small 
intestine.  It  is  particularly  useful  in  obstinate  cases,  and  is  there- 
fore prescribed  in  gastrogenic  diarrhea  and  ulcerative  processes. 
Tannyl  can  be  given  as  a  powder  or  in  tablet  form.  The  dose  of 
the  powder  is  0.6  Gm.  (10  grains)  or  more,  three  times  daily,  in  cocoa 
or  rice-soup.  The  tablets  should  be  well  broken  up  before  being 
taken;  two  tablets  may  be  taken  three  or  four  times  a  day. 

Milksomatose  occupies  a  unique  position  among  the  tannalbumin- 
ous  compounds,  because  of  its  solubility  in  water.  It  is  a  com- 
pound of  milk  casein  and  5  per  cent,  of  tannic  acid;  a  yellow-brown 
powder,  odorless  and  nearly  tasteless.  The  dose  for  adults  is 
three  tablespoonfuls  or  more  several  times  a  day;  for  children, 
one  to  three  teaspoonfuls.  Soup,  bouillon,  milk,  claret  or  tea  can 
be  used  as  a  vehicle.  Because  of  its  solubility,  milksomatose  is 
well  borne;  it  has  a  distinctly  astringent  effect.    (See  page  192.) 

Tannigen,  or  diacetyltannin,  has  proved  to  be  a  useful  astrin- 
gent in  both  acute  and  chronic  catarrh  of  the  intestine.  The  adult 
dose  is  0.5  to  1  Gm.  (7  to  15  grains),  the  dose  for  children  0.25 
to  0.3  Gm.  (4  to  5  grains),  several  times  daily. 


278  MEDICATION  IN  INTESTINAL  DISEASES 

Preparations  having  similar  actions  are:  Tannoform,  a  conden- 
sation product  of  tannic  acid  and  formaldehyd,  given  in  doses 
of  0.3  to  0.5  Gm.  (5  to  7  grains);  and  tannopin,  a  compound  of 
tannin  and  hexamethylamin,  dose  0.5  to  1  Gm.  (7  to  15  grains) 
three  or  four  times  a  day.  These  two  preparations  are  useful 
as_  antiseptics  also.  Tannigen  is  the  least  soluble  in  the  gastric 
juice,  tannopin  and  tannoform  more  soluble,  and  tannalbin  the 
most  freely  soluble  of  the  four.  Tannoform  is  most  easily  soluble 
in  the  intestine,  followed  in  order  by  tannigen,  tannalbin,  and 
tannopin. 

^  Agar  can  be  impregnated  with  various  drugs,  and  on  administra- 
tion convey  their  therapeutic  properties  to  all  parts  of  the  intestine. 
Agar-tannin  is  such  a  combination,  useful  in  all  cases  of  chronic 
diarrhea.  I  have  used  it,  following  the  suggestion  of  Einhorn,  with 
gratifying  results.  The  dose  is  a  teaspoonful  three  times  a  day. 
(See  page  287.) 

A  number  of  vegetable  drugs  are  employed  because  of  the  tan- 
nic acid  they  contain.  Gambir  has  taken  the  place  of  the  catechu 
of  the  Pharmacopoeia  of  1890.  It  is  an  extract  prepared  from  the 
leaves  and  twigs  of  Ourouparia  Gambir,  and  contains  a  large  per- 
centage of  tannic  acid  and  its  compounds.  Gambir  was  introduced 
on  account  of  the  difficulty  of  obtaining  in  the  market  true  acacia 
catechu.  The  Tinctura  Catechu  Compositse  and  the  Trochisci 
Catechu  (U.  S.  P.  1890)  are  replaced  by  Tinctura  Gamoir  Com- 
positse (average  dose,  4  Cc.)  and  Trochisci  Gambir,  U.  S.  P.  1910 
(average  dose,  1  Gm.). 

Krameria  has  similar  astringent  properties;  it  is  administered  as 
an  extract,  0.3  to  0.6  Gm.  (5  to  10  grains) ;  fluidextract,  0.3  to  2  Cc. 
(5  to  30  minims);  or  tincture,  2  to  8  Cc.  (5ss-ij). 

Tincture  of  kino  is  prescribed  in  the  dose  of  1  to  8  Cc.  (15  to 
120  minims). 

Tannic  acid  is  a  constituent  of  salvia  (leaves)  and  Quercus  alba 
(bark  and  fruit — infusion  of  the  former  and  preparations  of  the 
latter  as  acorn  cocoa  and  acorn  coffee). 

Hematoxylon  (logwood)  has  been  used  for  a  long  time  as  an 
astringent,  and  is  well  borne  by  the  stomach  even  when  its  use 
is  prolonged.  It  may  be  given  as  the  extract,  0.3  to  1  Gm.  (5  to 
15  grains)  several  times  daily  in  pills  or  in  claret.  Recently  a 
fine,  brick-red  powder  has  been  made  by  the  action  of  formaldehyd 
on  hematoxylon,  which  is  called  almatein.  It  is  particularly  recom- 
mended for  the  treatment  of  tubercular  intestinal  diseases.  It  is 
given  in  capsules  or  as  pastilles  in  doses  of  0.5  to  1  Gm.  (7  to  15 
grains)  four  to  six  times  a  day. 

Ipecacuanha  root  has  a  feeble  astringent  effect. 

The  tannin  contained  in  all  the  above-mentioned  preparations 
has  only  a  slight  astringent  effect  on  the  gastric  mucous  membrane, 
because  the  tannic  acid  is  liberated  very  slowly  from  the  drug. 


ANTISEPTICS  AND  ANT1  FERMENT ATIVEB  279 

The  extracts  are  preferable  to  the  tinctures  because  they  are  less 
irritating  to  the  gastric  mucous  membrane. 

The  employment  of  whortleberries  and  blackberries  in  the  diet  of 
intestinal  diseases  is  based  on  the  large  amount  of  tannic  acid  they 
contain. 

The  salts  of  some  metals  exert  a  similar  but  milder  astringent 
effect  upon  the  mucous  membrane  of  the  intestine.  This  is  espe- 
cially true  of  the  compounds  of  bismuth.  The  physiologic  action 
of  bismuth  on  the  intestinal  mucous  membrane  is  believed  to  be 
as  follows:  the  compounds  of  this  metal  unite  chemically  with 
the  hydrogen  sulphid  that  is  freely  evolved  during  the  processes 
of  decomposition,  and  are  precipitated  as  an  indifferent  sulphid  of 
bismuth  upon  the  inflamed  or  ulcerated  mucous  membrane,  thus 
forming  a  protective  coating.  The  bismuth  preparations  at  the  same 
time  act  as  antiseptics  (see  page  265). 

Silver  nitrate,  protargol  and  other  salts  of  silver  are  not  now 
employed  internally  in  the  treatment  of  intestinal  diseases. 

Lactic  acid  has  been  recommended,  particularly  in  tuberculosis. 

{b)  Protectives. — Protectives  have  the  property  of  covering  the 
inflamed  or  ulcerated  intestinal  mucous  membrane  with  a  thin 
protective  layer,  in  a  manner  similar  to  that  ascribed  to  bismuth 
in  ulcer  of  the  stomach.  Among  these  remedies  are  the  calcium 
preparations,  calcii  carbonas  prsecipitatus,  calcii  phosphas  prsecipi- 
tatus,  calcii  salicylas,  and  creta  prseparata.  These  drugs  have 
well-marked  astringent  and  antiseptic  properties;  they  are  given 
as  powders,  either  alone  or  combined  in  equal  parts,  in  teaspoonful 
doses,  three  times  daily.  Recently  clay  (bolus  alba)  has  been  used 
in  acute  and  chronic  diarrhea,  and  it  seems  to  act  well  as  a  protec- 
tive in  such  cases.  In  acute  enteritis  it  has  been  given  suspended 
in  water,  in  doses  of  60  to  100  Gm.  (gij-iij).  Talcum  may  be  em- 
ployed in  a  similar  manner;  large  doses  of  it,  however,  are  necessary 
— 60  to  100  Gm.  at  each  administration. 

Kaolin  (bolus  alba,  porcelain  clay)  and  talcum  (talc)  have  a 
slightly  astringent  action,  but  they  are  more  useful  as  protectives. 
The  virtue  of  kaolin  depends  upon  its  power  of  removing  bacteria 
and  toxins  from  mucous  membranes  by  mechanical  absorption. 

Antiseptics  and  Antifermentatives.— Abnormal  processes  of  putre- 
faction and  fermentation  in  the  intestine  are  apt  to  continue 
and  to  keep  up  the  inflammatory  changes  of  the  intestinal  mucous 
membrane;  they  may  also  increase  peristalsis,  and  give  rise  to 
pains  and  other  disagreeable  sensations  through  the  formation  of 
gases  which  distend  the  abdomen  (meteorism).  The  diseased 
intestinal  mucous  membrane  is  therefore  benefited  indirectly 
when  it  is  possible  to  check  or  to  diminish  such  decomposition 
processes.  This  can  be  accomplished  up  to  a  certain  degree  by 
the  antifermentative  and  antiseptic  drugs.       To  this  class  belong 


280  MEDICATION  IN  INTESTINAL  DISEASES 

the  already  mentioned  drugs  tannoform,  tannopin  and  tannyl,  sali- 
cylate of  bismuth,  and  calcium  salicylate.  The  antifermentative 
effect  of  salicylic  acid,  it  will  be  remembered,  was  mentioned  when 
discussing  the  effect  of  salicylic  milk  (see  page  176).  It  may  be 
said  that  the  salicylic  preparations  are  the  best  antifermentative 
agents  for  the  intestine.  Apart  from  those  referred  to,  attention 
may  be  drawn  to  magnesium  salicylate  in  doses  of  1  to  2  Gm.  (15  to 
30  grains)  three  times  daily.  It  acts  particularly  well  in  gaseous 
fermentation,  even  in  the  absence  of  diarrhea,  and  is  not  as  con- 
stipating as  bismuth  salicylate.  Bismuth  bisalicylate  (gastrosan) 
may  be  given  in  these  cases.  Salol  and  acetylsalicylic  acid,  0.5 
to  1  Gm.  (7|  to  15  grains)  several  times  a  day,  may  occasionally 
be  used  with  good  results  in  intestinal  diseases. 

Calomel  was  formerly  considered  the  best  intestinal  antiseptic. 
It  was  supposed  that  in  the  stomach  the  calomel  was  converted 
into  an  albuminate  which,  passing  onward  to  the  alkaline  pancreatic 
juice,  was  there  partially  oxidized  into  corrosive  sublimate  in  the 
presence  of  sodium  chlorid.  Other  writers,  however,  hold  that 
the  only  antiseptic  effect  of  calomel  is  that  which  results  from  its 
mild,  non-irritating  purgative  action,  as  in  the  case  of  any  other 
mild  purgative.  Thus  it  may  be  termed  an  antiseptic  by  virtue 
of  its  stimulating  effect  upon  the  transudation  of  liquid  into  the 
lumen  of  the  gut — the  bacteria  being  washed  out  of  the  mucous 
membrane.  However,  since  Strasburger  demonstrated  an  actual 
increase  in  the  number  of  intestinal  bacteria  during  the  administra- 
tion of  calomel  this  drug  has  not  been  considered  of  much  value  as 
an  antiseptic.  On  the  other  hand,  recent  researches  in  Schmidt's 
clinic  make  it  appear  that  calomel  does  not  always  increase  the 
number  of  bacteria,  but  very  frequently  reduces  it. 

Magnesium  peroxid  acts  as  an  antiseptic  by  the  liberation  of 
oxygen,  and  is  in  effect  probably  related  to  peroxid  of  hydrogen. 
Peroxid  of  hydrogen  acts  in  the  small  intestine  as  it  does  in  the 
stomach.  It  increases  the  natural  secretions  of  the  intestinal 
mucous  membrane,  and  thus  increases  the  natural  antiseptic 
power  of  the  parts.  Moreover,  it  literally  flushes  the  bacteria  out 
of  the  mucous  membrane.  Perhaps,  in  addition,  it  has  a  directly 
germicidal  effect  on  the  bacteria  in  consequence  of  the  liberation 
of  oxygen.  Pure  peroxid  of  hydrogen  is  promptly  decomposed 
both  in  the  air  and  in  the  stomach.  Schmidt  recommends  impreg- 
nating pure  agar  with  it,  this  vehicle  having  the  property  of  giving 
off  the  peroxid  slowly,  so  that  it  passes  through  the  stomach  into 
the  intestine  without  decomposition.  In  the  intestine  it  is  decom- 
posed instantly;  peroxid  agar,  or  "oxygar,"  is  therefore  available 
in  cases  of  disease  of  the  small  intestine  in  which  the  lesion  is 
situated  high  up,  but  in  the  lower  parts  of  the  intestine  no  effect 
can  reasonably  be  expected  from  this  preparation.    It  is  adminis- 


ANTISEPTICS  AND   ANTIFERMENTATIVES  281 

tered  in  the  dose  of  1  Gra.  (15  grains)  three  times  a  day  in  a  water 
or  in  a  little  water. 

Pure  betanaphtol  is  rarely  used.  Boas  prescribes  bismuth  beta- 
naphtol  quite  frequently.  Rodari  warmly  recommends  benzonaphtol. 

This  preparation  exerts  its  effeet  directly  in  the  intestine;  it  passes 
through  the  stomach  unchanged  and  breaks  up  in  the  intestine, 
giving  oil'  tree  naphtol.  It  does  not  irritate  the  intestine.  It  is  given 
in  the  dose  of  2  to  4  Gm.  (5ss-j)  a  day. 

Ichthyol  is  said  to  prevent  decomposition  quite  well.  It  is  given 
in  pills,  0.1  Gm.  (2  grains)  every  two  hours.  It  may  be  given  as 
an  albuminous  compound — ichthalbin,  which  has  the  advantage 
of  being  tasteless  and  insoluble  in  acid  gastric  juice.  The  dose  for 
children  is  0.1  to  0.3  Gm.  (2  to  5  grains)  and  for  adults  2  Gm. 
(30  grains)  several  times  a  day.  The  administration  of  ichthyol 
is  occasionally  followed  by  slight  gastric  discomfort  and  eructation. 

Other  remedies  are  creosote  and  its  derivatives.  Creosote  itself 
is  given  in  pills  or  capsules  of  0.05  Gm.  (1  grain)  four  or  five  times 
a  day.  Pills  with  enteric  coating,  rendering  them  insoluble  in  the 
stomach,  are  available.  A  good  substitute  for  thfc  preparation 
is  guaiacol  carbonate;  but  proposote,  a  compound  of  creosote 
and  phenylpropionic  acid,  is  better.  Thiocol  has  been  recently 
recommended.  It  inhibits  peristalsis,  and  decreases  hypersecre- 
tion and  the  number  of  bacteria;  does  not  irritate  the  stomach;  and 
is  given  in  doses  of  0.5  Gm.  (8  grains)  three  times  a  day,  preferably 
in  the  form  of  tablets.  Enterol,  a  cresol  preparation;  stryacol, 
an  acid  ester;  and  nosophen  (tetraiodophenolphthalein)  are  some- 
times used.  Iodoform  is  of  some  value  in  certain  intestinal  dis- 
eases (dysentery).  Thyol  in  rather  large  doses — 4  to  6  Gm.  (5j-iss) 
daily — in  capsules,  acts  as  an  antiseptic.  Menthol  may  be  given 
in  the  dose  of  0.1  to  1  Gm.  (2  to  15  grains)  several  times  a  day,  in 
capsules.  Resorcinol  may  likewise  be  employed  in  the  same  manner 
as  in  gastric  diseases.  Saccharin  in  full  doses  acts  as  an  antifer- 
mentative.  A  pure  culture  of  lactic  acid  bacilli  (Metchnikoff)  has 
been  used;  its  antiseptic  effects  are  fully  described  in  discussing 
yoghurt  (see  page  164). 

Yeast  also  has  much  power  of  destroying  the  toxicity  of  patho- 
genic bacteria.  The  yeast  of  beer  is  frequently  used  for  the  purpose 
of  disinfecting  the  intestinal  tract. 

The  first  principle  in  the  treatment  of  intestinal  diseases  must 
always  be  to  obtain  full  control  over  the  pathologic  condition  by 
purely  dietetic  measures,  long  continued  rest,  and  avoidance  of 
all  irritation.  These  measures  failing,  it  is  advisable  to  assist  a 
regulated  diet  by  the  giving  of  astringent  and  antifermentative 
remedies.  Astringents  are  contra-indicated  in  those  cases  in  which 
inflammation  and  diarrhea  have  arisen  from  decomposition;  the 
removal  of  the  decomposing  contents  is  the  rational  treatment. 


282  MEDICATION  IN  INTESTINAL  DISEASES 

PURGATIVES. 

The  effect  of  purgative  remedies  depends  upon  stimulation  of 
the  peristaltic  movements  of  the  intestine,  and  partly  upon  lique- 
faction of  the  stools.  The  latter  is  brought  about  by  an  increase 
in  the  natural  secretion  of  the  mucous  membrane  of  the  intestine, 
from  the  irritating  effect  of  the  purgative  agent,  or  by  an  increased 
transudation  of  serous  fluid  into  the  lumen  of  the  intestinal  canal. 
The  increase  in  peristalsis  is  brought  about  by  local  stimulation  of 
the  mucous  membrane  and  its  nerves,  causing  a  reflex  stimulation 
of  the  motor  ganglia  of  the  intestine.  Some  drugs  act  in  this 
manner  on  the  whole  intestinal  canal,  while  others  act  only  on  the 
large  intestine.  This  depends  on  the  comparative  facility  or  diffi- 
culty of  absorption  of  the  medicaments;  the  more  resistance  there 
is  to  absorption,  the  more  general  will  be  the  peristaltic  effect.  All 
purgatives  stimulate  peristalsis;  many,  in  addition,  increase  the 
amount  of  liquid  in  the  intestine.  This  fact  has  been  controverted 
up  to  the  very  present.  Attempts  have  been  made  to  explain  the 
liquefaction  of  the  stools  by  saying  that  the  absorption  of  water 
from  the  bowel  is  diminished  by  the  purgative  and  the  accelerated 
peristalsis.  Later  researches  have,  however,  shown  that  this  does 
not  play  any  very  conspicuous  role.  Adolf  Schmidt  insists  that,  as 
a  rule,  the  diarrhea  is  referable  to  the  secretion  of  an  albuminous 
decomposable  fluid  within  the  lumen  of  the  gut — "No  diarrhea 
with  increased  peristalsis  without  secretion  of  a  decomposable 
fluid  by  the  intestinal  membranes."  Thus  an  explanation  is  offered 
for  the  strongly  pronounced  decomposition  processes  which  are 
found  in  diarrheic  stools.  This  increase  of  intestinal  fluids  is 
caused  by  a  great  variety  of  agencies — bacterial  irritation,  thermic 
and  chemical  stimuli,  coarse  foods  ill  digested  in  the  stomach  (e.  g., 
raw  connective  tissue),  and  similarly  by  a  large  number  of 
purgatives. 

A  general  distinction  is  made  between  aperients,  which  affect 
only  the  peristaltic  movements  and  render  defecation  normal  both 
as  to  frequency  and  consistency;  laxatives,  which  induce  semisolid 
or  liquid  stools;  and  the  drastics  which  cause  profuse  watery 
diarrhea  and  intense  inflammatory  irritation  of  the  mucous  mem- 
brane. The  latter  need  not  be  considered  from  a  therapeutic 
standpoint.  This  classification  possesses  but  little  practical  value, 
inasmuch  as  the  aperients  become  laxatives  and  the  laxatives 
cathartics  when  given  in  large  doses,  and  vice  versa.  It  is  the  dose 
only  which  makes  the  difference.  The  occurrence  of  pains,  often 
of  a  colicky  nature,  after  each  evacuation,  results  from  the  violently 
stimulated  peristalsis  and  the  irritation  of  the  sensory  nerves  of 
the  intestine. 

Indications  for  the  Administration  of  Purgatives. — Conditions  of 
acute  constipation  require  a  purgative  unless  they  are  caused  by 


PURGATIVES  283 

inflammatory  changes  or  by  stenosis  of  the  intestine.    Should  any 

doubt  exist  regarding  these  latter  conditions,  it  is  better  to  give 
an  enema.  When,  however,  a  purgative  is  indicated,  one  ought 
to  be  selected  which  acts  promptly  and  surely,  and  a  large  dose 
should  be  given.  When  the  stomach  is  diseased,  calomel  is  the 
best  drug;  and  when  the  stomach  is  normal,  castor  oil.  It  must 
not  be  forgotten  that  purgatives  may  cause  great  disturbance 
to  the  gastric  secretion.  The  administration  of  any  purgative 
ought  to  be  discontinued  as  soon  as  possible.  In  cases  of  chronic 
intestinal  stasis,  purgatives  are  unavoidable  and  act  more  surely 
than  enemata,  but  only  mild  drugs  should  be  employed,  that  irri- 
tation of  the  diseased  intestine  may  be  avoided.  Purgatives  are 
indicated  in  those  cases  of  atonic  constipation  only  in  which  it 
has  been  found  impossible  to  obtain  results  by  means  of  dietetic 
and  physiotherapeutic  methods.  They  should  be  used  in  cases 
of  acute  intestinal  catarrh  in  order  to  bring  about  as  rapidly  as 
possible  an  evacuation  of  the  decomposed  and  disintegrating  fecal 
masses.  Purgatives  in  such  cases  act  literally  as  antiseptics, 
inasmuch  as  they  wash  out  the  bacteria  from  the  mucous  mem- 
brane by  stimulating  the  normal  glandular  secretion.  Calomel  and 
phenolphthalein  are  particularly  valuable  in  these  conditions. 
When  the  bowel  is  completely  occluded,  the  use  of  enemata  is, 
of  course,  the  only  proper  treatment.  Purgatives  should  not  be 
given  in  the  atonic  constipation  of  youthful  patients;  and  they 
are  absolutely  contra-indicated  in  spastic  constipation.  It  is  a  dis- 
tinct therapeutic  error  to  treat  constipation  in  cases  of  chronic 
enteritis  by  means  of  purgatives. 

Certain  drugs  which,  though  they  have  no  specific  purgative 
action,  assist  in  the  passage  of  feces,  should  be  mentioned  here. 
Opium  must  be  placed  first  in  this  respect,  as  being  the  most 
important.  Its  action  in  placing  the  bowels  at  rest  and  thus  caus- 
ing the  cessation  of  cramps  has  already  been  described.  Opium 
relaxes  the  intestinal  muscle  fibers  and  thereby  opens  the  way  for 
the  free  passage  of  fecal  matter  in  cases  of  spastic  constipation. 
Atropin  acts  very  similarly ;  its  action,  however,  is  not  so  decided  as 
that  of  opium.  In  large  doses  it  has  a  paralyzing  effect  upon  the 
nerve  endings.  Atropin  may  therefore  be  combined  with  opium. 
Atropin  sulphate  is  given  subcutaneously  and  in  pills  or  tablets; 
maximum  single  dose,  0.001  Gm.  (^  grain).  The  extract  of  bella- 
donna may  be  given  in  doses  of  0.015  Gm.  (J  grain);  when  used 
for  any  length  of  time,  caution  is  advisable,  lest  poisoning  result. 
Atropin  may  be  replaced  by  eumydrin,  twenty  drops  of  a  1:1000 
solution  three  times  daily.  Physostigmin  (eserin)  has  a  stimu- 
lating effect  on  peristalsis;  it  directly  influences  the  contractile 
muscles.  Though  employed  largely  in  veterinary  medicine,  it  is 
always  somewhat  dangerous  in  human  practice  and  should  be  used 
only  in  extreme  cases.     In  severe  tympanites,  ileus,  meteorism, 


284  MEDICATION  IN  INTESTINAL  DISEASES 

and  paralysis  of  the  intestine  after  operations,  physostigmin  is 
sometimes  prescribed;  in  such  cases  it  is  given  in  the  form  of 
physostigmin  salicylate  in  doses  of  0.0006  to  0.002  Gm.  (y^o  to 
^q  grain).  There  is  nothing  more  reliable,  however,  for  the  pre- 
vention or  relief  of  postoperative  intestinal  paresis  than  pituitrin 
(pituitary  extract),  administered  hypodermically  or  intravenously; 
the  dose  is  1  to  2  Cc.  of  the  standard  preparation,  or  half  this 
quantity  of  pituitrin  "surgical."  Strychnin  stimulates  peristalsis 
and  is  given  to  adults,  especially  after  operations,  in  doses  of  0.003 
Gm.  (2V  grain),  being  preceded  by  a  saline  purgative.  For  the  relief 
of  spasm,  benzyl  benzoate  in  doses  of  2  Cc.  (30  minims)  may  be 
given  with  any  of  the  above  named  preparations. 

The  number  of  drugs  used  as  purgatives  proper  is  extremely 
large.  The  mildest  purgatives  are  the  fruit  acids,  especially  when 
they  are  taken  as  slowly  absorbable  acid  salts  (tartrates,  citrates) 
or  in  combination  with  colloid  materials  (pectin,  vegetable  mucus) 
and  mild  laxative  carbohydrates  (sugar).  A  large  number  of  fruits 
(as  apples  and  grapes)  contain  a  mixture  of  these  materials  and 
for  this  reason  play  an  important  role  in  the  dietetic  treatment  of 
constipation.  Grape  juice  contains  acid  potassium  tartrate.  Some 
kinds  of  jam  (pulpse)  occupy  an  intermediary  position  between 
foods  and  purgatives;  e.g.,  prune  jam  (pulpa  prunorum),  elderberry 
jam  (pulpa  sambuci),  quince  jam  (pulpa  cassia  fructus),  and  tama- 
rind jam  (pulpa  tamarindorum  depurata),  and  the  marrow  of 
the  skins  of  Tamarindus  indica  made  into  a  confection.  The  latter 
contains  a  mixture  of  citric,  malic,  and  tartaric  acids,  and  acts 
as  a  purgative  in  doses  of  15  to  30  Gm.  (§ss-j).  The  confection 
senna?  consists  of  powdered  senna,  tamarind,  fig,  oil  of  coriander, 
cassia,  prune,  and  sugar,  neutralized  by  means  of  carbonate  of 
magnesium;  dose,  4  to  8  Gm.  (5HJ).  Manna  belongs  to  this 
group;  it  is  the  dried  juice  of  Fraxinus  ornus  (habitat  South  Italy), 
containing  60  to  80  per  cent,  of  the  active  principle  mannite. 
Manna  in  doses  of  15  to  60  Gm.  (§ss-ij)  acts  as  a  mild  purgative, 
but  is  not  used  as  much  as  formerly.  Of  the  carbohydrates,  various 
kinds  of  sugar  (cane-sugar,  grape-sugar,  and  milk-sugar)  act  as  mild 
purgatives.  The  latter  two  are  somewhat  more  active  than  the 
first  mentioned.  The  mild  purgative  effect  of  honey  is  due  to 
the  presence  of  these  sugars. 

The  various  substances  mentioned  above  belong  to  the  aperient 
group.  Those  now  to  be  considered  are  usually  classed  among 
laxatives.  A  few  inorganic  salts  may  first  be  mentioned,  which 
are  especially  represented  by  sodium  sulphate  (Glauber  salt)  and 
magnesium  sulphate  (Epsom  salt).  These  salts  act  by  contact  as 
slight  irritants.  Even  in  small  doses  they  are  laxative,  because 
they  are  capable  of  passing  along  the  whole  length  of  the  intestine, 
being  not  easily  diffused  or  absorbed.  This  is  due,  partly,  to  their 
ability  to  unite  chemically  with  a  large  quantity  of  water.     Not 


PURGATIVES  285 

only  are  they  absorbed  slowly,  but  they  hinder  the  absorption  of 
water;  moreover,  they  stimulate  intestinal  secretion  and  transuda- 
tion, causing  liquid  evacuations.  The  effect  of  these  salts  on  diges- 
tion has  been  studied  by  means  of  roentgenograph  ic  observations. 
It  is  seen  that  the  salt  solution  retards  the  motility  of  the  stomach 
but  strongly  accelerates  the  passage  of  the  chyme  through  the 
small  intestine,  liquefies  the  contents  of  the  large  intestine,  and 
urges  the  feces  to  the  sigmoid  flexure,  so  that  in  a  few  hours  there 
results  a  thin,  watery  stool.  These  salts  are  given  in  doses  of  15 
to  30  Gm.  (one  to  two  tablespoonfuls)  dissolved  in  a  glass  of  warm 
water;  they  are  best  taken  in  the  morning,  one  hour  before  breakfast. 
It  is  a  good  plan  for  the  patient  to  take  some  exercise,  because  bodily 
motion  accelerates  the  passage  of  the  saline  solution  from  the 
stomach  into  the  intestine  and  also  aids  in  the  onward  motion 
of  the  fecal  mass.  If  exercise  be  neglected,  it  may  be  that  the  salts 
will  produce  no  effect.  This  is  the  reason  why  these  laxatives  are 
not  prescribed  for  patients  confined  to  bed.  When  employed 
correctly  the  mineral  salts  do  not  cause  any  pain,  but  induce  a 
free  defecation  in  from  one-half  hour  to  three  hours.  The  same 
effects  are  produced  by  Carlsbad  salts  because  of  the  Glauber 
salt  they  contain,  and  by  all  the  well-knowrn  mineral  waters  con- 
taining Glauber  salt.  As  a  rule  Glauber  salt  is  preferred  to  Epsom 
salt,  on  account  of  its  better  taste.  To  improve  the  taste,  lemon 
juice  may  be  added  to  any  of  these  salt  solutions. 

To  this  group  of  salts  belong  quite  a  number  of  others  which 
have  a  similar  action.  Potassium  bitartrate  (cream  of  tartar), 
soluble  in  water,  has  an  agreeable  acidulous  taste.  It  is  a  mild 
purgative,  combining  the  saline  and  acid  effects  in  doses  of  2  to  15 
Gm.  (5ss-iv).  Potassium  and  sodium  tartrate  (Rochelle  salt), 
readily  soluble  in  wTater,  has  a  cooling  saline  taste  and  is  admin- 
istered in  doses  of  8  to  30  Gm.  (3ijH5J).  Sodium  phosphate  is  a 
mild  purgative  with  a  saline  taste,  and  is  readily  soluble  in  water; 
the  dose  is  0.3  to  3  Gm.  (5  to  45  grains).  Liquor  magnesii  citratis 
(solution  of  magnesium  citrate),  a  solution  of  magnesium  citrate 
with  excess  of  citric  acid  and  carbon  dioxid,  is  marketed  in  corked 
and  wired  bottles;  it  effervesces  when  the  bottle  is  uncorked;  dose, 
60  to  240  Cc.  (5ij-viij). 

Sulphur  is  a  mild  purgative.  It  is  insoluble  in  the  stomach, 
where  it  causes  no  discomfort.  It  is  dissolved  in  the  alkaline 
intestinal  juice,  but  so  slowly  and  in  such  small  quantities  that 
the  greater  part  is  expelled  unaltered.  The  alkaline  sulphur  com- 
pound formed,  however,  suffices  to  stimulate  peristalsis  along  the 
entire  intestinal  canal.  Sulphur  is  employed  in  the  form  of  sulphur 
sublimatum  in  doses  of  1  to  4  Gm.  (15  to  60  grains),  and  as  sul- 
phur prsecipitatum  in  the  same  dose. 

Hydrargyri  chloridum  mite  (calomel,  chloric!  of  mercury)  is  a 
prompt-acting,  mild  purgative,  and  may  always  be  given  in  inflam- 


286  MEDICATION  IN  INTESTINAL  DISEASES 

matory  conditions.  It  passes  through  the  intestinal  canal  for  the 
mostJpart|undecomposed,  but  during  its  entire  passage  small 
quantities  are  dissolved,  which  manifest  their  activity  by  their 
effect  on  the  ganglia.  The  difficulty  of  solution  and  absorption 
explains  the  great  efficacy  of  calomel.  The  small  quantities  dis- 
solved are  converted  into  the  sulphid  of  mercury,  and  probably 
also  into  the  bichlorid.  The  calomel  stool  looks  green — which 
is  due  to  its  containing  biliverdin,  the  conversion  of  which  into 
urobilin  is  prevented  by  the  calomel.  The  dose  of  calomel  is  0.006 
to  0.3  Gm.  (-yo  grain  to  5  grains)  several  times  daily.  This  mercurial 
purgative  is  not  suitable  for  prolonged  administration,  because  of 
the  danger  of  producing  constitutional  symptoms. 

Oleum  ricini  (castor  oil),  the  fixed  oil  (light  yellow,  viscid) 
expressed  from  the  seed  of  Ricinus  communis,  has  an  action  similar 
to  that  of  calomel,  being  both  mild  and  effective.  It  contains 
the  ester  of  ricinoleic  acid,  which,  when  liberated  in  the  gut  by  the 
saponifying  action  of  the  pancreatic  juice,  becomes  active.  Castor 
oil  acts  mechanically  also,  lubricating  both  the  mucous  membrane 
and  the  fecal  mass.  It  may  be  employed  in  inflammatory  condi- 
tions. The  evacuations  following  its  use  are  painless  and  semi- 
solid. The  dose  is  15  to  30  Gm.  (one  to  two  tablespoonfuls).  Its 
nauseating  taste  makes  it  difficult  of  administration  to  sensitive 
persons  and  children;  but  it  may  be  given  in  elastic  gelatin  capsules. 
Tasteless  preparations  of  castor  oil  are  sold  in  the  shops. 

Another  group  of  vegetable  purgatives  that  are  freely  employed 
belongs  imder  one  heading,  because  the  active  principles  are  either 
identical  or  closely  related  to  one  another.  These  are  senna, 
rhubarb,  and  aloes.  The  active  principles  of  these  plants  are  deriva- 
tives of  anthracene  which,  with  sugar,  form  glucosides.  These 
medicinal  agents  are  further  related  by  the  fact  that  they  are 
active  only  in  the  large  intestine. 

A  vegetable  cathartic  that  is  frequently  employed  is  podophyllum 
(May  apple,  mandrake).  It  is  a  yellowish  powder  which  is  sepa- 
rated from  the  alcoholic  extract  of  the  root  of  Podophyllum  pel- 
tatum  by  the  addition  of  water.  The  active  principle,  podophyllin, 
is  a  mild  purgative;  it  is  prescribed  in  small  doses — 0.008  to  0.03 
Gm.  (|  to  \  grain). 

Jalap  and  colocynth  are  drastic  purgatives.  On  account  of  their 
irritating  properties  and  the  depression  following  their  use  they  are 
rarely  prescribed. 

Phenolphthalein  is  met  with  under  many  commercial  names.  It 
is  a  mild  laxative,  and  induces  painless  evacuation  of  the  bowel. 
It  is  also  said  to  possess  some  disinfectant  action.  It  strongly 
stimulates  intestinal  secretion  and  sweeps  out  the  bacteria  which 
are  settled  in  the  lower  folds  of  the  mucous  membrane  and  in  the 
lymphatic  channels.  Clinical  experience  proves  that  phenol- 
phthalein is  a  valuable  purgative.    The  discovery  of  this  property 


PURGATIVES  287 

was  purely  accidental.  The  chemical  was  being  used  to  color 
artificial  Hungarian1  wines  and  thus  prevent  their  substitution 
for  genuine  wine.  Those  who  drank  the  artificial  wines  suffered 
from  diarrhea,  and  as  soon  as  they  discontinued  their  use  the 
diarrhea  ceased.  Phenol phthalein  passes  through  the  acid  stomach 
unchanged,  but  reaching  the  intestine  some  of  it  combines  with  the 
alkaline  substances,  forming  a  sodium  salt.  This  latter  is  of  low 
diffusive  power  and  its  presence  induces  a  high  osmotic  pressure 
resulting  in  a  copious  accumulation  of  fluids.  It  is  said  that  85 
per  cent,  of  the  drug  ingested  is  found  in  the  feces.  Its  presence 
can  be  readily  demonstrated  by  adding  an  alkali  to  the  feces,  when 
a  purple  color  will  quickly  develop. 

Phenolphthalein  causes  evacuation  of  the  bowel  in  about  six 
hours  after  the  dose  is  taken.  Its  use  is  not  followed  by  increased 
tendency  to  constipation,  as  is  the  case  with  many  other  purgatives. 
It  may  be  given  in  capsule,  powder,  or  pill.  The  dose  is  0.06  to  0.3 
Gm.  (1  to  5  grains)  once  daily  or  oftener.  Recently  it  has  been 
stated  that  irritation  of  the  kidneys  and  abdominal  pain  occasion- 
ally follow  the  use  of  phenolphthalein.  It  is  therefore  advisable 
to  exercise  some  caution  in  its  administration. 

The  special  physiologic  action  of  agar  and  liquid  petrolatum  will 
be  discussed  in  the  chapter  on  Chronic  Constipation  (XXXVII). 
Agar  will  absorb  fluid  medicaments  and  later  gradually  liberate 
them,  thus  ensuring  the  application  of  the  medicament  to  large 
areas  of  the  intestinal  mucosa.  To  prepare  medicated  agar,  the 
medicinal  agent  is  dissolved  in  boiling  agar-water,  and  the  solution, 
thoroughly  mixed,  evaporated  to  the  original  dry  agar  volume. 

The  following  combinations  have  been  suggested  by  Einhorn: 

Phenolphthalein-agar.  Each  level  teaspoonful  equals  0.03  Gm. 
(|  grain)  phenolphthalein. 

Rhubarb-agar.  Each  teaspoonful  equals  1  Cc.  (15  minims)  fluid- 
extractum  rhei. 

Calumba-agar.  Each  teaspoonful  equals  2  Cc.  (30  minims)  fluid- 
extractum  calumbse. 

Gambir-agar.  Each  teaspoonful  equals  2  Cc.  (30  minims)  tincture 
gambir  composite. 

Tannin-agar.  Each  teasponful  equals  0.03  Gm.  (f  grain)  tannic 
acid. 

Simaruba-agar.  Each  teaspoonful  equals  1  Cc.  (15  minims) 
tinctura  simaruba?. 

Phenolphthalein-agar  and  rhubarb-agar  can  be  conveniently  used 
in  the  different  varieties  of  constipation.  One  teaspoonful  of  either 
in  water,  twice  daily,  is  the  average  dose. 

Calumba-agar  has  proved  valuable  in  cases  of  colitis  (appearance 
of  considerable  mucus  in  the  stool)  with  normal  defecation.    The 

1  Gilbride:  Journal  of  the  American  Medical  Association,  January  29,  1910. 


288  MEDICATION  IN  INTESTINAL  DISEASES 

average  dose  is  one  teaspoonful  in  water,  after  meals  (three  times  a 
day).     --  £• 

Gambir-agar,  tannin-agar  and  simaruba-agar  are  valuable  in 
diarrheal  conditions,  acute  or  chronic.  The  average  dose  is  one 
teaspoonful  three  times  a  day,  after  meals  (see  page  277). 

Aloin,  apocodein,  eserin,  atropin  and  eumydrin  have  been  injected 
subcutaneously.  It  has  been  found  that  this  method  of  adminis- 
tration is  not  injurious.  The  subcutaneous  injection  of  magnesium 
sulphate,  cascara  sagrada,  pituitary  extract  and  hormonal  is  fully 
described  in  Chapter  XXXVII — Constipation. 


CHAPTER  XV. 
DISEASES  OF  THE  MOUTH. 

The  mouth  may  be  anatomically  divided  into  two  principal 
parts:  the  anterior  or  actual  cavity,  containing  the  tongue,  the 
organs  of  taste,  the  teeth,  and  the  orifices  of  the  salivary  glands; 
and  the  posterior  or  bucco-faucial  cavity,  also  called  the  isthmus 
faucium,  extending  from  the  soft  palate  to  the  epiglottis. 

For  conciseness  of  terminology  the  following  additional  sub- 
divisions have  been  named:  (1)  the  vestibulum  oris,  the  space 
between  the  teeth  and  the  cheeks  and  lips,  demarcated  posteriorly 
by  the  junction  of  the  main  oral  cavity  and  the  isthmus  faucium; 
(2)  the  lingual  region,  characterized  by  abundant  musculature, 
peculiar  formation  of  the  papillae,  the  follicular  glands,  and  the 
terminations  of  the  nerves  of  taste;  (3)  the  fundus  of  the  mouth, 
an  irregular  fissured  space  demarcated  anteriorly  by  the  lower 
teeth,  laterally  by  the  submaxillary  bones  and  their  teeth.  Under- 
neath the  buccal  fundus  are  situated  the  submaxillary  salivary 
glands,  resting  upon  the  geniohyoglossus  and  mylohyoid  muscles. 
These  muscles  separate  the  fundus  from  the  subcutaneous  con- 
nective tissue  of  the  neck.  The  transition  to  the  faucial  cavity 
is  formed  by  the  tonsillar  region,  which  likewise  includes  the  fol- 
licles at  the  base  of  the  tongue.  All  the  organs  of  the  oral  cavity, 
with  the  exception  of  the  teeth,  are  invested  with  epithelium. 
The  various  parts  of  the  mucous  membrane  differ  considerably, 
according  to  the  quantity  of  glands  and  their  manner  of  adhesion 
to  their  base.  The  epithelium  everywhere  consists  of  striated 
pavement  cells,  and  resembles  the  epithelium  of  the  external  skin 
except  as  regards  firmness,  which  is  normal  to  the  red  part  of 
the  lips  and  the  dorsal  aspect  of  the  tongue  only.  The  epithelial 
layer  is  rather  thin  at  the  inner  labial  mucosa,  while  at  the  dental 
margins  and  on  the  surface  of  the  tongue  it  attains  to  considerable 
thickness.  The  vascular  supply  of  the  mucosa  of  the  mouth  is 
very  abundant.  The  course  of  the  veins  corresponds  in  a  general 
way  to  that  of  the  arteries.  There  is  also  a  dense  net  of  lymph 
vessels  and  lymph  nodules  in  the  mucous  membrane  and  other 
structures  of  the  oral  cavity. 

The  fact  that  the  oral  cavity  is  so  frequently  the  seat  of  patho- 
logic affections  is  explained  by  the  incessant  introduction  of  micro- 
organisms by  means  of  food  and  eating  utensils,  the  fingers  and 
the  respired  air.  The  moist  heat  prevailing  in  the  mouth  furnishes 
19 


290  DISEASES  OF  THE  MOUTH 

a  most  favorable  condition  for  their  growth,  and  it  is  therefore  not 
to  be  wondered  at  that  an  exceedingly  large  number  of  many 
varieties  of  bacteria  are  demonstrable  in  that  cavity.  As  a  matter 
of  course,  the  number  and  kind  of  bacteria  differ  according  to  the 
method  of  examination  and  the  time  bestowed  upon  it,  and  also 
upon  the  care  given  to  the  cleansing  of  the  mouth.  The  various 
bacteria  cannot  be  readily  differentiated,  for  the  reason  that  many 
of  them  cannot  be  grown  at  all,  or  only  with  great  difficulty,  on 
an  artificial  culture  medium.  There  is  no  doubt  that  many  of 
those  that  cannot  be  artificially  grown  are  harmless,  inasmuch 
as  they  are  nearly  always  present  in  healthy  individuals.  Besides, 
there  are  numerous  pathogenic  microorganisms  in  the  oral  cavity, 
notably  the  Staphylococcus  pyogenes  aureus  and  albus,  and  more 
frequently  even  the  Streptococcus  pyogenes.  There  are  also 
numerous  pneumococci.  Tubercle  bacilli  are  frequently  found 
in  the  mouths  of  tuberculous  persons,  leprosy  bacilli  in  leprous 
individuals,"  and  typhoid  bacilli  in  typhoid  cases.  These  micro- 
organisms may  have  gained  secondary  access  to  the  oral  cavity. 
Constitutional  infections  are  not  infrequently  caused  by  the  micro- 
organisms entering  through  the  mouth  and  gaining  access  to  the 
circulation  by  deglutition,  respiration,  or  direct  absorption.  It 
is  probable  that  they  can  also  enter  through  the  epithelial  crypts 
of  the  tonsils.  A  simple  examination  of  the  tonsil  can  be  made 
by  depressing  the  tongue  with  a.  laryngeal  mirror  placed  well  back 
at  its  base  and  pressed  against  the  tonsil  at  its  lower  border.  By 
drawing  the  mirror  upward,  in  this  manner  milking  the  tonsil,  any 
infection  would  become  apparent,  as  pus  would  show  on  the  surface 
of  the  mirror. 

Oral  Sepsis. — There  is  a  close  relationship  between  oral  sepsis, 
alimentary  toxemia,  and  intestinal  stasis.  Lane  asserts  that  pyor- 
rhea alveolaris  is  caused  by  intestinal  stasis  (see  page  697) .  Chronic 
constipation  produces  alimentary  toxemia.  The  absorption  of 
toxins  poisons  the  whole  system,  inducing  functional  disturbances 
and  organic  diseases  of  a  more  or  less  serious  nature.  The  oral 
cavity,  providing  a  fruitful  soil,  soon  becomes  infected.  On  the 
other  hand,  pus  which  has  formed  around  the  teeth  and  gums  is 
carried  into  the  intestinal  canal,  inducing  or  aggravating  a  general 
septic  condition.  The  whole  process  is  known  as  intestinal  toxemia. 
The  absorption  of  toxins  from  the  alimentary  tract  devitalizes 
the  system  and  lowers  its  powers  of  resistance.  Both  oral  sepsis 
and  intestinal  stasis  must  be  corrected  in  order  to  bring  about 
recovery  in  many  obscure  diseases  (see  page  689) . 

Focal  Infection.— Hygiene  of  the  mouth  is  one  of  the  most  impor- 
tant considerations  in  the  treatment  of  diseases  of  the  digestive 
organs.  Experimenters  have  been  able  to  induce  in  the  lower 
animals  gastric  and  duodenal  ulcer,  cholecystitis,  pancreatitis, 
appendicitis,  neuritis,  oophoritis,  rheumatism,  arthritis  deformans, 


PLATE    XXIII 


Focal  Infection. 

Apical  abscesses  and  gum-boil. 


FOCAL  INFECTION  291 

goiter,  enlarged  lymph  glands,  and  local  and  general  diseases,  by 
intravenous  injection  of  specific  microorganisms  taken  from  the 
mouth.  Oral  sepsis  oilers  a  focus  of  infection,  acting  as  a  pre- 
dominating factor  hi  the  causation  of  gastro-intestinal  diseases. 
Diseases  of  the  mouth  may  cause  secondary  infection  through  the 
blood  stream,  or  the  bacteria  may  be  squeezed  out  of  the  pathologic 
tissue  during  mastication  and  carried  with  the  food  to  the  stomach 
and  intestine.  These  bacteria  have  the  power  to  so  modify  their 
surroundings  as  to  enable  them  to  perpetuate  themselves  indefinitely. 
They  have  what  may  be  called  a  pathogenic  affinity  for  certain 
organs  of  the  body,  and  are  able  to  adapt  themselves  to  new  environ- 
ments. Streptococci  may  change  their  type  and  develop  an  elective 
affinity  for  specific  tissues;  this  transmutation  is  quite  common. 
The  parts  of  the  body  that  are  particularly  prone  to  become  the  seat 
of  focal  infection  causing  systemic  diseases  are  the  teeth,  gums, 
tonsils,  sinuses,  gall  bladder,  appendix,  and  genito-urinary  tract.  A 
pyorrheal  or  tonsillar  abscess  may  be  the  focus  of  a  gastric  or  duo- 
denal ulcer,  or  of  a  diseased  gall  bladder  or  appendix.  Rosenow  has 
demonstrated  that  the  virulence  of  streptococci  is  increased  in 
proportion  as  they  are  deprived  of  oxygen,  and  that  virulent  strep- 
tococci produce,  on  direct  inoculation,  a  great  variety  of  organic 
infections  (see  Plate  XXIII). 

It  has  long  been  recognized  that  the  full  significance  of  focal 
infections  is  not  confined  to  their  place  of  origin  or  location,  but 
is  to  be  found  to  a  far  greater  extent  in  the  widespread  metastases 
which  may  be  located  at  great  distances  and  apparently  have  no 
connection  whatever  with  the  original  focus.  The  very  fact  that 
the  accepted  synonym  for  focal  is  "circumscribed'''  or  "confined" 
illustrates  the  fallacy  under  which  old-time  investigators  labored; 
instead  of  being  the  end,  the  focus  is  too  often  only  the  beginning  of 
the  infectious  process,  which  spreads  to  those  tissues  of  the  body 
which  have  an  elective  affinity  for  the  invading  microorganism  or 
related  strains.  Since  Rosenow  has  succeeded  in  establishing  the 
transmutability  of  streptococci  into  pneumococci,  it  can  be  easily 
understood  that  the  vista  of  possibilities  in  regard  to  infectious 
metastases  has  only  just  been  opened. 

Susceptibility  to  infection  is  determined  not  only  by  the  con- 
dition of  the  individual  exposed,  but  also  by  his  habits,  diet,  occupa- 
tion, age,  environment,  climate,  and  even  sex,  or  by  trauma.  If  the 
infection  is  complicated  by  a  secondary  infection,  the  latter  may  be 
unrecognized  in  the  original  focus,  but  will  assert  itself  in  the 
selection  of  metastatic  foci  in  the  distant  parts  of  the  body  which 
have  a  selective  affinity  for  one  or  another  of  the  species  of  micro- 
organisms involved. 

Metastasis  of  this  kind  is  dependent  upon  mutation  in  bacterial 
pathogenicity  of  the  strepto-pneumococcus  group.  Once  the  danger 
of  metastastic  development  is  properly  recognized,  the  systemic  dis- 


292  DISEASES  OF  THE  MOUTH 

ease  will  prove  to  be  preventable,  or  amenable  to  proper  treatment 
when  brought  to  the  notice  of  the  physician.  In  other  words, 
progressive  ill-health  from  apparently  unexplainable  causes  may  be 
prevented  or  cured  by  the  removal  of  chronic  foci  anywhere  in  the 
body,  and  the  full  attention  and  energy  of  the  physician  should  be 
directed  to  their  discovery.  A  systemic  infection  from  unrecognized, 
unsuspected  or  unremoved  chronic  foci  may  continue  for  years, 
gradually  poisoning  the  system.  Even  if  one  infected  focus  has  been 
discovered  and  removed,  and  the  systemic  disease  does  not  clear  up, 
it  does  not  follow  that  the  theory  is  wrong;  in  all  probability  there  is 
yet  another  focus  of  infection  which  will  have  to  be  searched  for  and 
removed  to  ensure  success. 

Any  part  of  the  body  may  harbor  a  focal  infection;  and  the  recog- 
nition of  the  fact  that  these  infections  are  responsible  for  many 
diseases  which  the  profession  has  not  been  able  to  deal  with  satis- 
factorily on  the  principles  of  symptomatology,  has  gone  far  toward 
arresting  professional  attention  and  directing  it  on  the  right  path  in 
its  search  for  etiologic  factors.  Such  centers  of  focal  infection  are 
found  in  cholecystitis,  appendicitis,  submucous  abscesses,  salpingitis, 
vesiculitis  seminalis,  and  prostatitis;  but  the  one  site  to  which  the 
vast  majority  of  all  investigation  has  so  far  been  directed  as  the 
principal  offender  is  in  the  head,  in  and  about  the  tonsils,  the 
roots  of  the  teeth,  and  the  accessory  sinuses.     (See  Plate  XXIII.) 

Now  we  have  it  on  the  authority  of  all  the  authors  who  have 
concerned  themselves  with  the  investigation  of  this  question,  that 
the  acutely  inflamed  tonsil,  where  the  crypts  are  full  of  dead  cells, 
blood  and  dust  particles,  and  countless  bacteria,  may  be  the  focus 
from  which  may  arise  otitis  media,  sinusitis,  mastoiditis,  bronchitis, 
pneumonia,  gastric  and  duodenal  ulcer,  endocarditis,  myocarditis, 
pericarditis,  cholecystitis,  appendicitis,  iridocyclitis,  arthritis,  rheu- 
matic fever,  and  perhaps  other  diseases.  The  chronically  inflamed 
tonsil  with  pouting  crypts  may,  besides,  lead  to  nephritis  and 
interstitial  hepatitis. 

The  variations  in  the  strepto-pneumococcus  and  other  groups, 
while  first  discovered  in  cultures  grown  in  the  laboratory,  are 
apparently  also  present  in  focal  infections,  the  tissues  serving  as  a 
culture  medium.  Blood  supply,  oxygen  tension,  and  unknown 
biochemic  or  other  factors  modify  or  entirely  change  the  bacterial 
characteristics;  this  is  one  explanation  of  the  development  of 
arthritis  as  a  consequence  of  tonsillitis,  of  endocarditis  from  the 
presence  of  the  Streptococcus  viridans  or  hemolyticus  in  alveolar 
abscesses,  and  of  similar  affections  on  the  same  principle. 

The  Streptococcus  viridans  or  hemolyticus,  to  which  reference 
has  just  been  made,  has  a  special  pathogenicity  for  malignant 
endocarditis,  with  a  predilection  for  old  valvular  scars  and  the 
endocardium,  where  it  causes  the  development  of  enormous  vegeta- 
tions and  thrombus  formations.     The  only  hope  for  the  patient  in 


TREATMENT  OF  DISEASES  OF  THE  MOUTH  293 

these  cases  is  complete  eradication  of  the  original  focal  infection 
whence  the  germ  is  carried  into  the  circulation.  Myositis,  arthritis, 
ami  other  chronic  diseases  arc  instances  in  which  the  same  micro- 
organism exerts  its  baneful  influence  in  milder  degrees. 

The  specificity  of  the  strepto-pneumococcus  group  was  beyond 
the  pale  of  understanding  prior  to  the  remarkable  achievements  of 
Rosenow,  who  proved  the  transmutability  of  these  organisms.  An 
important  factor  in  this  transmutation  seems  to  consist  in  the 
oxygen  supply  of  the  tissues,  so  that  characteristics  may  develop 
which  render  the  organism  pathogenically  specific  in  the  myocardium, 
endocardium,  pericardium,  gall  bladder,  pancreas,  kidney,  mucous 
membranes  of  the  stomach  and  intestine,  tendons  and  aponeuroses. 

The  similarity  of  the  pathogenic  organisms  in  the  original  focus 
and  in  the  remote  infected  tissues  may  be  regarded  as  proving  the 
etiologic  relation  between  the  two,  for  many  bacteria  retain  for  a 
long  time  the  peculiar  properties  which  determine  their  character- 
istic localization.  The  idea  readily  suggests  itself  that  other  diseases, 
whose  etiology  is  still  obscure,  may  have  a  similar  origin,  and  there 
is  consequently  a  wide  field  open  for  further  research  work,  experi- 
mentation and  discovery. 

The  mouth  should  be  kept  free  from  infection  at  all  costs,  even 
though  it  should  mean  the  removal  of  every  tooth  in  the  head,  for 
a  toothless  mouth  is  preferable  to  one  containing  a  single  focus  that 
menaces  the  health  of  the  patient.  Frequent  roentgenograms  should 
be  taken,  not  only  to  discover  every  suspicious  root,  but  also  to 
inspect  from  time  to  time  all  crown  and  bridge  work,  in  order  to 
discover  any  disease  in  the  hidden  parts.  There  is  no  greater 
menace  to  health  than  crowned  and  bridged  teeth,  to  say  nothing 
of  imperfectly  filled  and  dead  teeth,  inasmuch  as  the  hidden  bacteria 
are  preserved  thereby  and  are  ever  ready  for  mischief.  No  dentist 
should  devitalize  a  tooth,  or  attempt  to  fill  the  roots  of  a  devitalized 
tooth  which  is  to  be  preserved,  without  the  aid  of  roentgenograms. 
(See  Plate  XXIII.) 

Constitutional  diseases  due  to  focal  sepsis  cannot  be  successfully 
treated  until  the  focus  of  infection  is  eliminated.  Hence  the 
necessity  for  thorough  exploration  of  the  mouth — for  the  suscepti- 
bility of  the  teeth  to  decay,  of  the  root  sockets  to  ulceration,  and  of 
the  tonsils  to  bacterial  attacks,  especially  streptococcic,  makes  it 
probable  that,  when  other  sources  of  infection  are  unknown,  the 
focus  is  in  the  mouth.  Especially  should  chronic  focal  sepsis  without 
pronounced  local  manifestations  be  looked  for,  since  its  metastatic 
consequences  are  most  serious. 

GENERAL  TREATMENT  OF  THE  DISEASES  OF  THE  MOUTH. 

Prophylaxis  is  of  the  greatest  importance  in  these  diseases,  as 
in  all  others.    Numerous  affections  of  the  mouth  are  preventable, 


294 


DISEASES  OF  THE  MOUTH 


provided  intelligent  care  be  taken  to  that  end.  Any  special  care 
of  the  mouth  of  nurslings  before  the  eruption  of  teeth  is  detri- 
mental, as  long  as  the  mouth  is  in  a  healthy  condition.  After  the 
teeth  appear,  the  infantile  mouth  requires  the  same  care  as  that 
of  the  adult. 

As  a  general  rule  it  will  be  sufficient  to  brush  the  teeth  carefully 
at  least  once  a  day  with  a  brush  and  a  suitable  tooth  powder, 
paste  or  soap;  and  to  mechanically  remove  food  remnants  by 
rinsing  after  each  meal  if  possible,  but  in  any  case  several  times 
a  day.  The  brush  should  be  applied  with  an  up-and-down  motion, 
for  the  double  reason  that  it  then  operates  best  to  remove  food 
particles  and  does  not  tend  to  cause  erosion  of  the  neck  of  the 
tooth.  It  should  be  applied  inside  as  well  as  outside  of  the  denture. 
The  following  tooth  powders  and  pastes  can  be  recommended : 


n 


Gm.  or  Cc. 
Calcii  carbonatis  praecipitati   .      .      .      9010 
Saponis,  I 

Camphorae aa       60 

Olei  menthse  piperita? 1 1 0 

Misce  et  ft.  pulv.  subtilis. 


1$ — Calcii  carbonatis  prsecipitati   ...      30 
Pulveris  iridis, 

Pulveris  calami aa     10 

Pulveris  myrrhae 5 

Olei  rosse 

Misce  et  ft.  pulv.  subtilis. 


Gm.  or  Cc. 
0 

0 
0 
3 


Gm.  or  Cc. 
0 
0 
01 


P, — Calcii  carbonatis  praecipitati   ...  60 

Pulveris  iridis 20 

Saccharini     . 0 

Sodii  bicarbonatis, 

Magnesii  oxidi aa  4 

Misce  et  ft.  pulv.  subtilis. 


E — Calcii  carbonatis  prsecipitati   ...  60 

Acidi  borici 40 

Saponis 40 

Saccharini •  0 

Aquae  ammonias 1 

Olei  menthae  piperita? 1 

Olei  rosae 

Glycerini,  q.  s. 

Misce  et  ft.  pasta. 


Gm.  or  Cc. 
0 
0 
0 

01 
0 
3 
1 


5iij 

3iss 
TUxv 


3iiss 
3iss 


5ij 
3v 
gr. 

5i 


Si] 

§1SS 

giss 
gr.  | 
TTlxv 
tt\xx 

mij 


Carious  teeth  must  be  repaired,  being  veritable  hotbeds  for  the 
growth  of  microorganisms.  Mechanical  cleansing  of  the  teeth  is 
much  more  important  for  the  purpose  of  removing  bacteria  from 
the  mouth  than  the  application  of  powerful  antiseptics.  The 
brush  should  be  applied  to  the  teeth,  including  the  inner  and 
masticating  surfaces,  both  transversely  and  vertically.  The 
removal  of  food  remnants  from  between  the  teeth  requires  the  use 
of  dental  floss.    Toothpicks  should  not  be  used,  for  they  are  incom- 


TREATMENT  OF  DISEASES  OF  THE  MOUTH  295 

patible  with  the  requirements  of  a  rational  hygiene  of  the  mouth, 
whether  they  are  made  of  wood,  metal,  or  any  other  material. 
The  habit  of  brushing  the  surface  of  the  tongue  is  to  be  deprecated, 
since  it  may  lead  to  atrophy,  fissure,  or  fragility  of  the  epithelium. 
Individuals  wearing  dental  and  palatal  protheses  should  subject 
these  to  very  careful  mechanical  cleansing,  and  remove  them  over- 
night. They  should  also  exercise  more  than  usual  care  in  main- 
taining a  healthy  condition  of  the  mouth. 

Mouth-washes  have  no  antiseptic  properties,  unless  they  contain 
such  drugs  as  menthol,  permanganate  of  potassium,  hydrogen 
peroxid,  thymol,  or  salol.  A  saturated  solution  of  sodium  silico- 
rluorid  makes  a  very  effective  mouth-wash  in  oral  infections.  The 
following  solutions  can  be  recommended:  boric  acid  (3  per  cent.), 
thymol  (0.05  per  cent.),  or  hydrogen  peroxid  (1  per  cent.). 

Gm.  or  Cc. 
1$ — Potassii  permanganatis       ....        110  gr.  xv 

Aquae  destillatae ad     50 10  oiss 

Misce. 
Sig. — Add  drop  by  drop  (5  to  10  drops)  to  a  glass  of  water  until  the  solution 
is  pink  or  light  violet. 

Gm.  or  Cc. 

1$ — Thymolis 1 1 0  gr.  xv 

Acidi  benzoici 6[0  oiss 

Tincturae  eucalypti 24 '0  ovj 

Aquae  distillates       .      .      .     q.  s.  ad  1500 1 0  Oiij 

Misce. 
Sig. — May  be  diluted,  and  used  as  a  mouth-wash. 

Aside  from  the  antiseptic  effect,  an  astringent  and  refreshing  action 
is  often  desirable.  This  is  accomplished  by  aluminum  acetate,  or 
by  tincture  of  myrrh,  rhatany,  or  nutgall. 

Gm.  or  Cc. 

1$ — Liquoris  alumini  acetatis        ...       60 1  §  ij 

Sig. — Thirty  drops  to  a  glass  of  water. 

Gm.  or  Cc. 

1$ — Tincturae  myrrhae, 

Tincturae  krameriae  .     aa       7 1 5  5  ij 

Misce. 
Sig. — Thirty  drops  to  a  glass  of  water. 

Persons  whose  occupation  predisposes  to  mouth  diseases  should 
exercise  great  caution  on  this  account.  Occupations  of  this  kind 
are  those  in  which  mercury,  phosphorus,  arsenic  or  lead  is  used. 
Minute  or  coarse  particles  of  these  poisons  are  apt  to  enter  the 
mouth,  in  the  work  rooms  or  by  contact  with  fingers  soiled  during 
work.  The  obvious  prophylaxis  is  adequate  supervision  and 
instruction.  It  is  equally  clear  that  careful  hygiene  of  the  mouth 
is  of  the  greatest  prophylactic  importance,  and  work-people  with 
carious  teeth  should  never  be  employed  in  any  of  these  occupations. 
It  is  well  known,  for  instance,  that  phosphorus  necrosis  never 


296  DISEASES  OF  THE  MOUTH 

occurs  except  in  the  presence  of  caries  of  the  teeth.  Other  occu- 
pations facilitate  the  spread  of  infectious  diseases  by  the  mouth, 
an  instance  of  which  is  furnished  by  the  frequent  spreading  of 
tuberculosis  and  syphilis  among  glass-blowers. 

Scrupulous  oral  hygiene  is  doubly  indicated  in  the  presence  of 
any  affection,  local  or  constitutional,  which,  not  originating  in 
the  mouth,  nevertheless  involves  the  mouth.  In  febrile  affections, 
such  as  typhoid,  pneumonia,  or  grave  septic  diseases,  changes  in 
the  mucosa  of  the  mouth  are  often  occasioned  by  swelling  and 
loosening  of  the  gums,  owing  to  heavy  coating  of  the  tongue  and 
disturbance  of  the  general  condition.  Patients  should  be  required 
to  rinse  their  mouths  and  brush  their  teeth  as  soon  as  they  are 
able  to  do  so.  Similar  measures  are  indicated  in  grave  affections 
of  the  brain  and  spinal  cord,  and  in  those  leading  to  severe  consti- 
tutional disorders  of  nutrition  (diabetes,  leukemia,  nephritis,  cardiac 
disorders,  etc.). 

The  rules  of  prophylaxis,  however,  will  not  avail  when  the  oral 
cavity  has  already  become  distinctly  affected.  The  most  impor- 
tant thing  then  is  to  keep  any  possible  detrimental  influence  away 
from  the  affected  areas.  Tooth-brushes,  frequently  sterilized, 
preferably  by  repeated  rinsing  in  hot  soap-water,  should  be  used 
with  the  greatest  caution;  they  should  not  be  applied  too  ener- 
getically. Filling  or  removing  carious  teeth  should  be  done  with- 
out delay,  in  order  to  avoid  mechanical  lesions  of  the  mucous 
membrane.  Ill-fitting  artificial  teeth  should  not  be  tolerated. 
Coarse  articles  of  food,  likely  to  irritate  the  mucous  membrane, 
should  be  avoided  (figs,  nuts,  etc.).  Highly  sugared  dishes,  which 
readily  lead  to  acidification,  are  not  permissible.  Voluble  talk- 
ing should  be  forbidden.  It  goes  without  saying  that  smoking, 
alcoholic  beverages  and  highly  spiced  dishes  should  be  excluded. 

In  spite  of  the  desirability  of  avoiding  mechanical  lesions,  the 
mouth  should  be  thoroughly  cleansed  in  all  serious  oral  affections. 
This  applies  especially  when  the  treatment  of  the  mouth  and 
tongue  is  hindered  by  pain  or  swelling,  which  preclude  the  automatic 
cleansing  by  the  tongue  and  the  mastication  of  food.  In  these 
cases  mouth-washes  are  necessary,  less  for  their  disinfecting  than 
for  their  purely  mechanical  effect.  For  this  purpose  any  of  the 
following  may  be  used:  Boric  acid  (3  to  4  per  cent,  solution), 
borax  (5  per  cent.),  menthol  (10  per  cent,  alcoholic  solution,  10 
to  20  drops  stirred  in  a  glass  of  water),  thymol  (0.1  per  cent.), 
hydrogen  peroxid.  Superabundance  of  sputum  or  mucous  secre- 
tion may  be  checked  by  aluminum  acetate  (a  teaspoonful  of  a 
2-per-cent.  solution  to  a  glass  of  water).  Pronounced  fetor  ex  ore 
and  the  sensation  of  bad  taste  associated  therewith  may  often  be 
removed  by  a  solution  of  potassium  permanganate  (0.025  to  0.05 
per  cent.)  or  hydrogen  peroxid  (1  per  cent.).  If  at  all  possible, 
patients  are  to  rinse  their  mouths  at  frequent  intervals  with  one 


TREATMENT  OF  DISEASES  OF  THE  MOI  Til  207 

of  these  washes.  Unfortunately,  they  arc  often  unable  to  do  so 
on  account  of  the  inflammatory  condition  of  the  mouth;  it  will 
then  be  necessary  to  wash  the  mouth  with  the  aid  of  an  irrigator 
or  syringe.  In  circumscribed  affections  which  are  not  readily 
accessible,  and  especially  in  the  presence  of  dry  deposits  defying 
easy  removal,  it  is  advisable  to  paint  the  affected  places  with 
mild  concentrated  antiseptics.  Very  effective  service  is  rendered 
by  the  boroglvcerid  mixture  and  the  following  combinations: 

Cm.  or  Cc. 

1$ — Tincturse  iodi, 

Tincturse  gallse, 

Tincturse  myrrhse aa     10  ]0  5hss 

Misce. 

Sig. — For  painting  the  gums,  lips  and  tongue. 

Gm.  or  Cc. 
1$ — Tincturse  gallse, 

Tincturse  myrrhse, 

Tincturse  kramerise       .      .      .      .  aa     10  ] 0  oiiss 

Misce. 
Sig. — For  painting  the  gums,  lips  and  tongue. 

Non-poisonous  antiseptic  substances  may  be  conveniently  admin- 
istered to  sore-mouthed  nurslings,  by  mixing  with  sugar  and 
wrapping  up  in  some  sterile  dense  covering,  the  bolus  being  then 
given  them  to  suck. 

Potassium  chlorate  may  cause  methemoglobinemia  and  methemo- 
globinuria  on  account  of  the  fact  that  in  severe  affections  of  the 
mouth  swallowing  of  the  irrigating  fluid  cannot  always  be  entirely 
avoided.  With  this  precaution,  the  use  of  a  saturated  solution  of 
potassium  chlorate  is  of  great  value. 

Altogether  indispensable  in  the  treatment  of  buccal  affections 
is  iodoform;  it  is  the  sovereign  remedy  in  all  lesions  of  the  mouth 
associated  with  loss  of  substance,  in  all  operative  or  traumatic 
defects,  and  in  ulcerous  processes  of  all  kinds. 

At  the  buccal  fundus  and  the  vestibulum  oris,  iodoform  is  best 
applied  in  the  form  of  gauze  (10  per  cent.).  This  is  inserted  in 
strips,  which  will  remain  in  position  owing  to  the  fact  that  in 
severe  and  painful  affections  of  the  mouth  the  patients  do  their 
best  to  avoid  all  movements  of  the  tongue  and  mouth.  Thus 
it  will  happen  that  the  gauze  remains  in  situ  undisturbed  for 
several  days,  during  which  time  the  affected  part  is  protected  and 
unmolested  by  extraneous  irritations  while  at  the  same  time  a 
very  effective  disinfection  is  being  accomplished.  This  saves  much 
pain  and  inconvenience,  such  as  are  unavoidably  associated  with 
irrigation  and  painting.  However,  the  gauze  will  not  remain 
undisturbed  at  the  palatal  roof,  at  the  inner  surface  of  the  alveolar 
processes,  or  at  the  soft  palate.  For  these  localities  iodoform  powder 
may  be  insufflated  upon  the  affected  parts,  or  iodoform  mass  painted 


298  DISEASES  OF  THE  MOUTH 

upon  them  with  a  gauze  or  cotton  pad.  The  edges  of  the  gums 
may  likewise  be  treated  with  either  powder  or  mass. 

Iodoform  mass  is  prepared  in  the  following  way:  The  quantity 
of  iodoform  decided  upon  is  mixed  with  about  10  parts  of  a  1 :  1000 
sublimate  solution,  2-per-cent.  phenol,  or  3-per-cent.  boric  acid,  and 
the  mixture  allowed  to  stand  for  twenty-four  hours  in  a  tall  graduate 
or  beaker,  after  which  it  is  decanted  and  ready  for  use.  Iodoform 
mass  has  no  unpleasant  by-effects  except  the  odor  and  occasionally 
slight  salivation.  It  follows  that  iodoform  treatment  is  advisable, 
above  all,  in  ulcerations  with  slimy  deposits,  severe  gangrenous 
stomatitis,  and  all  lesions  of  the  buccal  mucosa.  The  substitutes 
for  iodoform  are  not  complete  representatives. 

Cauterization  of  the  mucous  membrane  and  the  gums,  formerly 
much  resorted  to,  can  usually  be  dispensed  with.  Occasionally  it 
is  useful  in  the  beginning  of  severe  gingivitis.  Cauterizing  agents 
of  this  description  are:  Silver  nitrate  (in  the  shape  of  the  stick 
or  as  a  10-  to  20-per-cent.  solution),  chlorate  of  zinc  solution  (8 
per  cent.),  20-per-cent.  chromic  acid  solution,  or  chromic  acid 
crystals;  lactic  acid  in  solutions  of  from  80  per  cent,  to  concen- 
trated, especially  in  tuberculous  ulcers.  In  some  cases  lactic  acid 
is  excelled  both  in  efficacy  and  painlessness  by  a  pap  of  iodoform 
and  lactic  acid,  which  is  prepared  by  moistening  iodoform  powder 
with  a  little  alcohol  and  stirring  to  a  thick  mass  with  a  solution 
of  lactic  acid.  Corrosive  sublimate  may  be  used  as  a  cauterizer, 
the  following  form  being  particularly  suitable  for  application  to 
mucous  plaques : 

Gm.  or  Cc. 
^ — Hydrargyri  chloridi  corrosivi  ...       0 1 3  gr.  v 

Etheris, 
Alcoholis aa,     15 10  5iv 

Misce. 

Sig. — Apply  with  caution. 

A  very  difficult  problem  in  cases  of  severe  and  painful  oral  affec- 
tions is  sometimes  presented  in  the  matter  of  food  supply.  When 
the  affected  lips  and  teeth  have  difficulty  in  seizing  the  food,  or 
in  trismus,  all  fluid  or  semifluid  articles  of  diet  have  to  be  adminis- 
tered in  a  way  to  reach  the  base  of  the  tongue.  This  is  accomplished 
by  means  of  a  beaked  cup.  Should  the  oral  opening  be  even  too 
narrow  to  accommodate  this  vessel,  the  latter  may  be  provided 
with  a  thin  rubber  tube,  by  means  of  which  liquids  and  soup  con- 
taining finely  minced  meat  can  be  conveniently  conveyed  to  the 
base  of  the  tongue.  Instead  of  a  beaked  cup,  a  funnel  or  an  irri- 
gator with  a  rubber  tube  attached  will  answer  the  purpose.  When 
the  mouth  can  be  opened  a  little  farther,  the  necessary  quantity 
of  food  can  be  administered  with  a  small  spoon.  When  deglutition 
is  impeded,  liquids  and  liquid  foods  must  be  administered  very 
slowly.     Patients  can  often  aspirate  liquids  very  well  through  a 


ORAL  AFFECTIONS  IN  GENERAL  INTOXICATIONS       299 

glass  or  rubber  tube.  Infants  are  usually  given  the  ordinary  nursing 
bottle,  with  a  rubber  cap,  to  drink  from.  Painful  deglutition  can 
be  relieved  by  painting  or  spraying  with  a  5-per-cent.  cocain,  eucain, 
or  novocain  solution;  or  one  of  these  substances  may  be  adminis- 
tered as  tablets — cocain,  0.005  Gm.  (y1^  grain);  eucain  or  novo- 
cain, 0.01  Gm.  (|  grain).  Orthoform  and  anesthesin  may  also  be 
administered  as  powders.  Painful  ulcerations  are  covered  with  a 
mass  prepared  from  powdered  orthoform  or  anesthesin  and  glycerin. 
Should  these  substances  not  be  sufficiently  powerful,  or  should 
deglutition  be  impossible  from  whatever  cause,  a  pharyngeal  tube 
should  be  inserted  for  introducing  the  food.  This  may  consist 
of  a  simple  rubber  tube  or  catheter,  which  need  not  be  inserted 
farther  than  just  beyond  the  cricoid  cartilage,  the  food  passing 
through  the  esophagus  into  the  stomach  by  gravity.  Should  even 
this  procedure  cause  considerable  pain,  there  is  nothing  left  but  to 
introduce  the  tube  into  the  esophagus  through  the  inferior  nasal 
canal.  This  is  best  done  through  the  right  nostril,  the  tube  being 
anointed  with  oil  or  petrolatum.  When  the  interior  of  the  nose 
is  much  swollen  or  the  mucous  membrane  so  greatly  irritated 
as  to  cause  sneezing,  the  passage  of  the  tube  can  be  facilitated  by 
a  cocain  spray;  the  tube  is  then  rapidly  inserted  up  to  the  posterior 
faucial  wall,  and  the  patient  requested  to  sw^allow  as  it  glides  down. 
Entrance  of  the  tube  into  the  glottis  can  in  most  cases  be  pre- 
vented. If  no  cough  follows,  the  tube  is  sure  to  have  reached  the 
esophagus,  and  the  liquids  may  be  poured  in  without  causing  any 
pain. 

ORAL   AFFECTIONS   IN   GENERAL  INTOXICATIONS. 

Numerous  poisons  pathologically  affect  the  mouth,  either  by 
absorption  or  by  secretion  through  the  salivary  and  mucous  glands, 
or  by  both  processes  combined. 

Metals. — Mercury. — Among  metals,  mercury  occupies  the  first 
place.  Mercurial  stomatitis  is  a  characteristic  affection  resulting 
from  the  administration  of  mercurial  medicaments  or  from  the 
nature  of  the  patient's  occupation.  Mercury  may  be  conveyed 
directly  or  in  the  form  of  vapor  (from  inunction)  to  the  oral  mucosa. 
By  whatever  means  it  finds  its  way  into  tbe  organism,  it  is  secreted 
in  large  quantities  through  the  saliva  and  can  thus  give  rise  to 
stomatitis.  This  affection  nearly  always  attacks  the  teeth  first, 
preferably  at  and  behind  the  wisdom  teeth;  otherwise  it  usually 
commences  in  carious  teeth  and  roots.  The  gums  of  these  defective 
teeth  become  relaxed,  red  and  swollen,  w;ith  considerable  saliva- 
tion. Similar  changes  appear  in  the  neighboring  parts  of  the 
mucous  membrane  and  tongue,  after  which  the  process  spreads 
to  the  other  parts  of  the  gums  and  cheeks,  with  considerable  increase 
in  salivation.    The  edges  of  the  gums  exhibit  a  more  or  less  exten- 


300  DISEASES  OF  THE  MOUTH 

sive  zone  consisting  of  desquamated  epithelium,  detritus,  and 
putrefactive  bacteria,  and  covered  with  a  yellowish-gray,  slimy, 
malodorous  mass.  There  is  at  the  same  time  a  characteristic  fetor 
ex  ore  which,  in  stomatitis,  is  of  a  peculiar  metallic  character. 
Gradually  the  gums  commence  to  ulcerate  underneath  the  slimy 
layer;  the  ulcers  are  covered  with  a  thick  yellow  and  greenish 
lardaceous  deposit  and  are  surrounded  by  an  intensely  red  inflam- 
matory zone.  Similar  ulcers  may  appear  at  the  cheeks,  lips,  and 
teeth.  The  tongue  may  undergo  considerable  swelling,  showing 
the  impression  of  the  teeth.  This  condition  may  be  of  an  exceed- 
ingly tormenting  nature.  The  ill-smelling,  abundant  saliva  can 
only  with  difficulty  be  swallowed  or  expectorated,  and  escapes 
involuntarily  from  the  open  mouth  (salivation).  Swelling  of  the 
surrounding  soft  parts  may  cause  spasm,  rendering  ingestion  of 
food  almost  impossible.  The  surrounding  lymph  glands  may  swell, 
and  there  is  often  fever.  If  other  grave  manifestations  of  a  consti- 
tutional mercurial  intoxication  set  in  (diarrhea,  nephritis),  an 
originally  quite  harmless  stomatitis  may  change  into  a  serious 
vital  affection.  Deglutition  pneumonia  may  also  occur.  The  prog- 
nosis must  therefore  be  very  guarded  in  serious  cases.  The  diagnosis 
will  offer  no  difficulties,  especially  when  the  physician  thinks  of  the 
possibility  of  mercurial  poisoning. 

Prophylaxis. — Workmen  handling  mercury  should  be  urgently 
warned  as  to  the  dangerous  effects  of  this  metal  and  the  necessity 
of  carefully  cleansing  their  hands,  particularly  before  meals.  Ab- 
sorption of  mercurial  vapor  cannot  easily  be  guarded  against.  In 
inunction  treatment  the  anointed  parts  are  to  be  well  covered  and 
not  to  be  touched  unnecessarily.  Nurses  and  others  attending  to 
the  inunction  are  likewise  exposed  to  the  danger  of  infection. 

Treatment. — If  stomatitis  occurs  in  the  course  of  inunction 
treatment,  attempts  may  be  made  to  counteract  in  part  the  effect 
of  the  mercury  by  sulphur  baths.  Should  these  be  contra-indicated 
owing  to  the  gravity  of  the  syphilitic  affection,  arsphenamine  may 
be  used.  If  the  application  of  mercury  must  be  continued,  the  local 
treatment  should  be  very  energetic,  consisting  of  the  most  scrupu- 
lous'cleansing  of  the  mouth.  In  light  cases,  gargles  and  mouth- 
washes will  be  found  sufficient;  in  severe  ones  the  mouth  is  rinsed 
with  an  irrigator,  or  the  affected  parts  are  painted  with  a  soft 
cotton  swab  or  hair-brush.  Iodoform  mass  or  tamponade  with 
iodoform  gauze  is  likewise  indicated  in  severe  cases  (see  page  298). 

Bismuth. — An  affection  resembling  mercurial  stomatitis  is  caused 
by  bismuth,  the  injurious  effects  of  which  have  latterly  been  observed 
in  an  increasing  number  of  cases  since  the  practice  has  obtained  of 
filling  up  bone  cavities  with  bismuth  paste  in  chronic  ulcerations. 

The  treatment,  after  the  bismuth  deposits  have  been  removed, 
corresponds  to  that  of  mercurial  stomatitis. 


IN  CONSTITUTIONAL  INFECTIOUS  DISEASES  301 

Lead.  Stomatitis  is  often  caused  by  lead  poisoning  running  a 
chronic  course.  As  a  rule  there  is  relaxation  and  swelling  of  the 
mucous  membrane,  and  a  blue-lead  fringe  at  the  edges  of  the  gums 
resulting  from  deposits  of  minute  particles  of  lead  and  sulphur  into 
the  gums. 

Silver. — Silver  poisoning  is  characterized  by  argyrosis,  involving 
a  s]  lotted,  black -brown  discoloration  of  the  entire  mucous  mem- 
brane of  the  mouth,  a  discoloration  which  may  also  appear  on  the 
external  skin.     There  is,  however,  no  real  stomatitis. 

Metalloids. — Chronic  phosphorus  poisoning  is  caused  by  the 
handling  of  yellow  phosphorus.  The  stomatitis  occasioned  thereby 
commences  with  relaxation  and  swelling  of  the  mucous  membrane, 
particularly  of  the  gums,  and  very  rapidly  spreads  to  the  maxillary 
bones,  especially  the  lower.  Abscesses  undermine  the  mucous 
membrane  and,  perforating  them,  form  fistula?.  The  process  may 
extend  over  several  years,  finally  leading  to  extensive  destruction 
of  bone. 

In  the  interest  of  prophylaxis,  yellow  phosphorus  should  be 
banished  from  match  factories.  The  work-rooms  should  be  well 
ventilated  and  the  men  instructed  to  pay  careful  attention  to  the 
hygiene  of  the  mouth  and  teeth  as  well  as  to  cleanliness  of  the  hands. 

Treatment  consists  in  tamponing  the  abscesses  with  iodoform 
gauze  and  removing  the  necrotic  parts. 

Bromids  and  iodids  in  small  doses  occasionally  cause  loosening 
of  the  teeth  and  swelling  of  the  gums  and  abundant  salivation. 
There  is  a  peculiar  soft,  yellowish  deposit  upon  the  teeth,  accom- 
panied by  a  characteristic  fetor  ex  ore. 

Medicinal  Exanthems. — The  use  of  a  number  of  medicaments, 
notably  antipyrin,  quinin,  phenacetin,  and  acetylsalicylic  acid, 
occasionally  leads  to  efflorescences  of  the  oral  mucosa  in  the  form 
of  roundish  blisters  and  yellowish,  easily  bleeding  deposits.  There 
are  similar  efflorescences  upon  the  skin. 

AFFECTIONS   OF   THE  MOUTH  IN  CONSTITUTIONAL 
INFECTIOUS  DISEASES. 

Numerous  infectious  diseases  give  rise  to  characteristic  mani- 
festations in  the  oral  mucosa.  In  measles,  the  so-called  Koplik's 
spots  are  a  well-known  manifestation,  appearing,  before  the  erup- 
tion of  the  exanthem,  at  the  interior  lining  of  the  cheeks  and  lips 
as  irregular  red  patches,  in  the  center  of  which  are  bluish-white  or 
yellowish-white  spots. 

In  scarlet  fever  the  exanthem  of  the  skin  is  accompanied  by  deep 
reddening  of  the  oral  mucosa,  the  latter  being  very  dry.  The 
tongue  is  covered  with  a  heavy  coat,  which  desquamates  in  the 
course  of  two  or  three  days.  Its  upper  surface,  or  possibly  the 
entire  tongue,  is  very  red,  and  the  papilla?  are  considerably  swollen, 


302  DISEASES  OF  THE  MOUTH 

presenting  the  well-known  pictures  of  raspberry  or  strawberry 
tongue. 

In  rubeola  the  exanthem  of  the  skin  is  sometimes  preceded  by  a 
small,  tender,  spotted,  pink  exanthem  of  the  soft  palate  and  fauces. 

Varicella  is  often  localized  in  the  mouth,  especially  at  the  hard 
palate,  tongue,  and  gums.  As  soon  as  the  blebs  desquamate,  there 
appears  a  yellowish-white  shallow  ulceration,  closely  resembling 
stomatitis  aphthosa.  Consequently  errors  in  the  diagnosis  are  apt 
to  occur  unless  the  exanthem  is  of  a  very  characteristic  nature. 

Variola  is  sometimes  accompanied  by  severe  stomatitis  and 
ulcerous  disintegration  of  the  vesicles,  which  may  confluesce  into 
large  foci  with  an  ulcerous  coat,  causing  considerable  pain. 

It  sometimes  happens  that,  following  vaccination,  vaccine  pus- 
tules appear  on  the  mucous  membrane  of  the  mouth,  the  vesicles 
changing  to  shallow  ulcers  which  run  a  thoroughly  benign  course. 

In  typhoid  and  paratyphoid  the  anterior  palatal  arch  occasionally 
exhibits  ulcers  which  closely  resemble  mucous  plaques  and  heal 
within  a  few  days.  Similar  ulcers  may  simultaneously  appear  on 
the  lips,  cheeks,  dental  margins,  and  lingual  frenum. 

Foot-and-mouth  disease,  according  to  recent  investigations,  can 
infect  man,  causing  blebs  and  ulcers  in  the  mouth.  For  prophy- 
lactic purposes  it  is  important  to  see  to  it  that  milk  from  animals 
suffering  from  this  disease  is  not  used  for  alimentation. 

In  influenza,  stomatitis  and  herpoid  eruptions  are  of  frequent 
occurrence. 

DISEASES   OF   THE  MOUTH  IN  NON-INFECTIOUS   CONSTITU- 
TIONAL DISEASES. 

In  hemophilia  there  are  occasional  hemorrhages  into  the  gums. 
There  may  also  be  hemorrhages  into  the  tongue,  causing  consider- 
able swelling  in  some  parts  which  have  to  be  incised  in  order  to 
evacuate  the  blood. 

Chlorosis  sometimes  gives  rise  to  painful  rhagades  and  excoria- 
tions at  the  angles  of  the  mouth  and  the  dental  margins.  Changes 
of  this  kind  are  very  frequent  in  pernicious  anemia. 

Hemorrhages  of  the  gums  are  of  frequent  occurrence  in  purpura. 

Pronounced  stomatitis  occurs  in  scorbutus.  It  is  not  yet  defi- 
nitely decided  whether  this  disease,  as  well  as  purpura,  is  to  be 
regarded  as  infectious.  The  first  symptom  is  inflammation  of  the 
gums,  which  become  swollen  and  tender.  Gradually  the  edges 
become  necrotic  and  detach  themselves  in  shreds.  The  disease  is 
usually  confined  to  the  gums,  but  it  never  occurs  in  nurslings  or 
the  aged.  There  is  considerable  pallor  of  the  mucous  membrane, 
and  exaggerated  salivation.  The  prophylaxis  consists  of  rational 
oral  hygiene.  Stomatitis,  when  present,  is  treated  with  mouth- 
washes, and  disappears  under  appropriate  diet  and  care. 


EROSIONS  AND  BURNS  OF  THE  MOUTH  303 

Infantile  SCUTVy  (Barlow's  disease)  is  likewise  associated  with 
stomatitis,  swelling  and  bleeding  of  the  gums,  but  without  necrosis. 
Here,  again,  general  treatment  and  diet  will  rapidly  effect  a  cure. 

In  pregnanci/,  light  gingivitis  is  of  frequent  occurrence. 

Diabetes  mellitus  and  tabes  are  often  associated  with  pyorrhea 
alveolaris.     Stomatitis  also  occurs  in  gouty  indiridunlx. 

EROSIONS    AND   BURNS    OF   THE   MOUTH. 

Erosions. — Erosions  of  the  mouth  are  occasioned  by  the  use  of 
highly  concentrated  mouth-washes  or  by  swallowing  caustic  poisons. 

Erosions  due  to  mouth-washes  occur  comparatively  often.  The 
sensitiveness  of  the  oral  mucosa  toward  antiseptic  mouth-washes 
differs  in  different  individuals,  and  in  the  pathologic  mouth  is 
increased,  with  the  result  that  mouth- washes  which  normally  are 
well  tolerated  may  lead  to  erosions.  These  will  form  white  scabs 
with  reddened  and  thickened  areola,  which  usually  heal  within  a 
few  days.  These  scabs  are  found  for  the  most  part  at  the  margin 
of  the  tongue  and  epiglottis,  and  at  the  palatal  arches  and  uvula. 
Unless  the  possibility  of  erosions  due  to  mouth-washes  is  borne 
in  mind,  these  manifestations  may  give  rise  to  mistaken  diagnosis, 
as  for  instance  of  diphtheria  or  syphilis.  For  the  purposes  of  a 
differential  diagnosis  it  should  be  remembered  that  in  erosions  from 
mouth-washes  the  vallecula?  are  seldom  involved,  whereas  the  diph- 
theritic process  spreads  to  these  structures. 

Caustic  poisons,  such  as  concentrated  alkali  solutions,  lye, 
concentrated  soda  or  potash  solutions,  aqua  ammonia  and  the 
acids,  cause  much  severer  lesions.  Among  the  acids,  sulphuric, 
hydrochloric,  phenol  and  lysol  are  the  principal  offenders.  The 
erosions  caused  by  all  these  substances  present  the  same  general 
character.  The  scabs  are  at  first  pure  white  and  more  or  less 
protruding,  and  may  spread  over  a  large  area  of  the  oral  cavity. 
The  parts  most  prominently  affected  are  the  labial  margins,  tongue, 
and  soft  palate.  The  labial  scabs  gradually  dry  up,  forming  brown 
and  black  crusts.  The  scabs  of  the  mucous  membrane  are  gradually 
desquamated,  leaving  painful  gray-yellow  ulcers  behind,  the  borders 
of  which  are  more  or  less  reddened  and  swollen.  If  extensive  areas 
in  the  vicinity  are  considerably  swollen,  and  the  inflammatory  edema 
continues  spreading,  the  involvement  of  the  entrance  to  the  glottis 
may  cause  considerable  dyspnea  and  grave  danger  to  life. 

Treatment. — In  the  first  place,  the  poison  has  to  be  counteracted: 
acids  by  alkalis,  alkalis  by  acids.  To  alleviate  the  pain,  small 
pieces  of  ice  are  administered,  the  mucous  membrane  is  painted 
with  boroglyeerid,  and  an  anodyne  is  given.  Food  is  withheld  as 
far  as  possible,  and  artificial  feeding  resorted  to  if  necessary.  Ulcer- 
ous points  are  treated  with  iodoform. 


304  DISEASES  OF  THE  MOUTH 

Burns. — Though  the  mucous  membrane  of  the  mouth  has  a  com- 
paratively high  power  of  resistance  to  heat,  it  may  be  burned  by  hot 
liquids,  hot  potatoes,  etc.  Severe  scalding  may  result  from  inhaling 
hot  steam,  as  in  explosions.  High  degrees  of  heat  produce  blisters 
which  soon  burst,  also  thin  fibrinous  deposits,  and  swelling  and 
reddening  of  the  mucous  membrane.  The  pains  may  be  so  severe 
as  to  completely  prevent  all  movements  of  the  mouth  and  tongue. 

LESIONS   OF   THE   ORAL  MUCOSA. 

Traumatic  Lesions. — Traumatic  lesions  of  the  oral  mucosa  are 
due  to  extraneous  causes  and  to  injudicious  biting  movements. 
The  lips  are  often  injured,  contused  and  lacerated,  by  a  fall.  The 
gums  are  exposed  to  numerous  injuries  from  without  and  within. 
Injury  to  the  tongue  is  inflicted  by  the  teeth  in  biting;  in  the  case 
of  a  fall,  pieces  of  the  teeth  may  break  off  and  stick  in  the  tongue; 
or  foreign  bodies  (fish  bones,  splinters  of  bones)  may  penetrate 
the  tongue,  where  they  are  arrested  and  cause  ulceration.  Injuries 
of  the  hard  and  soft  palate  are  often  due  to  a  fall  with  the  mouth 
open.  The  malar  mucosa  is  often  injured  by  the  teeth  in  mastica- 
tion. 

Treatment. — Lesions  hi  the  oral  mucosa  have  a  tendency  to  heal 
smoothly.  Nearly  all  of  them  can  be  sutured,  with  the  exception 
of  those  of  the  fundus.  Suturing  is  at  the  same  time  the  best 
means  of  arresting  hemorrhages,  which  are  often  severe.  When 
a  wound  has  been  exposed  to  infection,  the  surfaces  should  be 
rubbed  with  iodoform  powder  prior  to  suturing.  When  the  wound 
is  situated  low  down,  and  particularly  on  the  floor  of  the  mouth, 
tamponade  with  iodoform  gauze  is  indicated. 

Thickening  of  Epithelium. — Glass-blowers  sometimes  suffer  from 
a  considerable  thickening  of  the  epithelium  of  the  malar  mucosa 
without  inflammatory  manifestations — a  form  of  leukoplakia.  Old 
glass-blowers  often  have  their  incisors  considerably  worn  down  by 
the  action  of  the  mouth-piece  of  the  blow  instrument. 

Palatal  Ulcers. — In  the  newborn,  palatal  ulcers  are  not  infre- 
quent. They  occur  either  in  the  center  of  the  hard  palate  or  in 
places  where  the  mucous  membrane  of  the  palate  is  elevated  by 
the  hamuli  pterygoidei  of  the  sphenoid.  They  are  found  only  in 
infants  whose  mouths  have  been  subjected  to  cleansing  procedures; 
those  who  have  not  been  so  maltreated  do  not  have  them.  Evi- 
dently, therefore,  they  develop  purely  from  mechanical  injuries 
of  the  mucous  membrane  due  to  cleansing.  The  ulcers  are  shallow 
excavations,  gray  to  yellow  in  color,  and  cause  no  complaint 
whatever,  nor  do  they  interfere  with  nutrition. 

Treatment. — Mechanical  cleansing  of  the  mouths  of  nurslings 
is  not  good  practice.  The  ulcers  will  heal  without  any  treatment 
and  without  cicatrization. 


STOMATITIS  305 

Lingual  Ulcers. — Infants  frequently  suffer  from  ulcers  of  the 
lingual  frenum  which  are  due  to  erosions  caused  by  the  sharp 
edges  of  the  lower  middle  incisors  while  the  infant  is  nursing  or 
coughing.  They  will  not  occur  when  the  edges  of  the  teeth  are 
smooth.  In  infantile  pertussis  these  ulcers  are  of  very  frequent 
occurrence. 

Treatment. — Sharp-edged  teeth  must  be  filed  down  or  removed. 

Traumatic  Tumors. — Traumatic  tumors  of  the  frenum  some- 
times occur  in  nurslings.  They  are  clearly  the  result  of  chronic 
injury  to  the  frenum  through  the  incisors  or  the  hard  edges  of  the 
gums.  Microscopically  they  are  seen  to  consist  of  connective 
tissue  covered  with  a  strongly  developed  epithelial  layer.  The 
growths  are  benign  and  give  rise  to  no  symptoms. 

Treatment. — Extirpation  of  the  tumor  and  removal  of  the  irri- 
tating teeth. 

STOMATITIS. 

Simple  or  Catarrhal  Stomatitis. — The  mouth  in  healthy  individ- 
uals with  sound  teeth  may  remain  free  from  pathologic  manifes- 
tations even  without  any  particular  care  being  bestowed  upon  it. 
Stomatitis  simplex  is  very  often  due  to  carious  teeth  and  excessive 
calcareous  deposits.  The  parts  of  the  gums  adjoining  these  deposits 
become  easily  inflamed  and  swollen,  presenting  a  red  or  blue -red 
discoloration.  Bulging  and  loosening  of  the  margins  of  the  gums 
may  increase,  accompanied  by  exaggerated  salivation,  and  the  teeth 
may  drop  out.  This  condition  is  often  associated  with  excessive 
fetor  ex  ore.  It  may  also  be  followed  by  a  complete  involvement 
of  the  oral  mucosa,  coating  of  the  tongue,  and  interference  with 
mastication  and  speaking.  There  may  even  be  fever.  Individuals 
suffering  from  nephritis,  diabetes  and  other  constitutional  diseases 
may  develop  stomatitis  even  though  their  teeth  are  sound. 

Treatment. — Unsound  teeth  are  to  be  removed,  and  the  oral 
cavity  and  the  teeth  carefully  cleansed  by  mechanical  means. 
Antiseptic  mouth-washes,  such  as  thymol  (1:2000),  acetate  of 
aluminum  (1:200-500),  or  permanganate  of  potassium  (1:2000- 
5000),  usually  effect  a  cure  in  a  short  time.  Inflamed  points, 
ulcers  and  the  margins  of  the  gums  may  be  rubbed  with  iodoform 
mass  (see  page  29S).  The  constitutional  affection  is  to  be  treated 
according  to  general  indications. 

Gangrenous  Stomatitis. — Inflammatory  processes  in  the  mouth 
easily  lead  to  necrosis  and  ulceration.  In  a  large  number  of  cases 
of  severe  ulcerating  stomatitis,  the  ulcers  and  the  secretion  have 
been  found  to  contain  the  same  bacteria  as  those  wThich  are  con- 
sidered responsible  for  Vincent's  angina.  It  is  justifiable,  on  the 
ground  of  these  very  frequent  findings,  to  regard  these  micro- 
organisms as  the  cause  of  ulcerating  stomatitis. 

The  most  frequent  form  of  gangrenous  stomatitis  is  the  ulcerating. 
20 


306  DISEASES  OF  THE  MOUTH 

Stomatitis  ulcerosa  occurs  very  frequently  in  children  between 
the  ages  of  five  and  ten;  it  may  occur  at  any  other  age,  but  only 
when  teeth  are  present.  It  is  found  in  cases  of  neglected  dental 
hygiene,  carious  teeth,  and  excessive  accumulation  of  calcareous 
deposits,  and  may  easily  be  the  consequence  of  grave  disorders 
of  nutrition  (diabetes,  scrofulosis,  rachitis,  scorbutus).  Mercurial 
stomatitis,  which  has  been  described  above,  likewise  belongs  to 
stomatitis  ulcerosa  according  to  its  clinical  course.  The  affection 
commences  with  the  gums,  which  become  swollen,  spongy  and 
bleeding.  As  a  consequence,  the  margins  of  the  gums  and  the 
malar  mucosa  opposite  develop  irregular,  sharply  demarcated, 
whitish  yellow  patches,  beneath  which  a  puruloturbid  fluid  may 
accumulate.  This  constitutes  an  epithelial  necrosis,  leading  to 
the  formation  of  ulcers  with  a  yellowish  slimy  base  and  surrounded 
by  serrated,  bulging,  bluish-red  margins.  The  ulcers  may  spread 
to  the  gums  and  the  floor  of  the  mouth,  penetrating  rather  deeply 
into  the  tissue.  This  condition  is  accompanied  by  a  peculiar 
putrescent  odor.  As  the  affection  proceeds,  the  distress  will 
increase,  notably  in  masticating,  swallowing,  and  speaking.  The 
tongue,  cheeks,  and  possibly  the  soft  parts  of  the  neck  may  be 
highly  edematous.  Under  certain  circumstances  general  sepsis 
follows  as  infiltration  of  the  soft  parts  of  the  buccal  fundus  and 
the  neck  proceeds. 

Treatment. — Removal  of  the  cause,  so  far  as  possible  (carious 
teeth) ,  and  omission  of  mercury.  Efforts  should  be  made  to  remove 
the  concretions  and  the  decomposed  and  necrotic  masses.  This 
will  be  best  accomplished,  especially  in  the  presence  of  considerable 
pain,  by  rinsing  the  mouth  with  tepid  antiseptic  fluids  by  means 
of  an  irrigator.  Astringent  and  antiseptic  mouth-washes  are  at 
once  indicated  if  the  patient  is  able  to  attend  to  their  application 
himself.  Such  remedies  are:  Borax  (1  :  30),  permanganate  of  potas- 
sium (1:2000-5000),  tincture  of  myrrh,  and  tincture  of  krameria. 
Hydrogen  peroxid  is  especially  useful,  being  very  efficacious  in 
loosening  the  necrotic  masses.  In  progressive  ulceration,  iodoform 
is  the  best  antiseptic,  the  diseased  parts  being  rubbed  with  iodo- 
form mass,  and  iodoform  gauze  inserted  in  appropriate  places  (see 
page  298).  Based  upon  the  favorable  results  obtained  in  a  few 
cases  of  Vincent's  angina  with  arsphenamine,  this  remedy  should 
also  be  borne  in  mind  in  the  treatment  of  ulcerous  stomatitis. 

Noma. — The  gravest  form  of  gangrenous  stomatitis  is  noma, 
a  rather  rare  affection.  A  characteristic  inciting  factor  has  not 
yet  been  discovered,  although  spirochete  and  fusiform  bacilli  have 
been  found,  as  in  ulcerous  stomatitis.  Noma  is  preeminently  a 
children's  disease  and  is  often  preceded  by  measles.  It  has  also 
been  observed  after  scarlet  and  typhoid  fevers,  pneumonia,  and 
after  the  administration  of  mercury.  Usually  the  affected  children 
are  in  a  poorly  nourished  condition.    The  affection  commences 


STOMATITIS  307 

with  salivation,  fetor  ex  ore,  and  the  signs  of  simple  stomatitis. 
Then  follows  in  most  eases  the  formation  of  a  vesicle,  at  first  bluish- 
red  but  later  blackish,  at  a  point  between  the  angle  of  the  month 
and  the  orifice  of  Stenon's  duct  opposite  the  first  and  second 
molars.  There  is  an  objectionable  odor.  The  cheek  becomes 
swollen  and  pale.  The  swelling  increases,  extending  upward 
toward  the  eye  and  nose.  Finally  the  infiltration  is  as  hard  as  a 
board .  Simultaneously  the  necrosis  extends  over  the  mucous  mem- 
brane. The  black,  discolored  portion  develops  into  a  brownish- 
black  area,  rapidly  involving  the  entire  surface  of  the  malar  mucosa. 
Outward  perforation  threatens,  as  evidenced  by  a  bluish-red  spot, 
increasing  in  extent,  which  finally  becomes  gangrenous  and  per- 
forates. The  perforation  gains  in  extent,  due  to  tissue  disintegra- 
tion, and  may  involve  the  entire  area  from  the  angle  of  the  mouth 
over  the  upper  and  lower  maxilla?  to  the  ear,  finally  exposing  the 
bone  behind  the  ear.  The  gangrenous  process  may  now  limit  itself, 
in  which  case  the  necrotic  mass  is  gradually  desquamated,  and  the 
defect  is  gradually  covered  with  granulation  tissue,  leaving  in  the 
end  an  exceedingly  disfiguring  scar.  In  about  70  per  cent,  of  the 
cases  death  results  from  inanition  or  sepsis.  The  duration  of  the 
disease  is  usually  from  eight  to  fourteen  days,  and  its  prognosis  is 
always  very  grave. 

Treatment. — In  the  initial  stage  an  attempt  should  be  made  to 
extirpate  the  pathologic  focus,  but  in  spite  of  extensive  excision 
the  gangrene  often  persists  in  its  course.  After  extirpation,  Paque- 
lin  scarification  may  be  resorted  to;  this  failing,  the  treatment  must 
be  confined  to  the  relief  of  pain,  regulation  of  the  diet,  and  removal 
of  the  ichor  and  gangrenous  masses  by  irrigation.  Patients  must 
be  isolated,  owing  to  the  pestiferous  odor  they  exhale. 

Erysipelatous  Stomatitis. — It  is  only  in  rare  cases  that  erysipelas 
spreads  from  the  facial  skin  to  the  oral  cavity.  When  this  does 
occur,  there  is  diffuse,  intense  reddening,  desiccation  and  painful- 
ness  of  the  mucous  membrane.  The  uvula  may  be  swollen.  The 
pain  may  render  swallowing  impossible.  Stomatitis  erysipelatosa 
can  be  assumed  to  exist  with  certainty  when  erysipelas  has  preceded 
the  attack  or  follows  it.     The  tongue  may  swell  considerably. 

Treatment.- — Careful  oral  hygiene,  small  pieces  of  ice,  scarifica- 
tion of  the  mucous  membrane,  and  if  necessary  artificial  feeding. 
Colloidal  electro-silver  is  administered  intravenously  with  good 
results. 

Aphthae. — This  affection  is  characterized  by  the  early  appearance, 
with  febrile  manifestations,  of  pale  yellow  patches,  either  singly 
or  in  large  numbers.  They  may  be  very  small  or  as  large  as  a 
small  pea,  and  surrounded  by  a  slightly  elevated,  very  red  fringe. 
They  are  sharply  demarcated,  round  or  oval  in  shape.  In  most 
cases  they  undergo  rapid  resolution  by  becoming  detached  from  their 
base,  the  epithelium  simultaneously  growing  over  the  traumatic 


308  DISEASES  OF  THE  MOUTH 

surface  from  the  surrounding  area.  The  affection  usually  takes 
a  tedious  course,  numerous  new  foci  making  their  appearance. 
It  attacks  all  parts  of  the  mouth,  least  often  the  gums.  Each 
individual  focus  is  intensely  painful,  often  interfering  with  mas- 
tication, deglutition,  and  articulation.  Coincidently  the  patient 
suffers  from  a  moderate  degree  of  general  stomatitis,  exaggerated 
salivation,  fever,  and  more  or  less  malaise.  Aphthous  stomatitis 
might  also  be  designated  stomatitis  maculofibrinosa ;  its  cause  has 
not  yet  been  discovered  with  certainty.  Staphylococci  are  not  infre- 
quently present.  In  most  cases  the  affection  is  confined  to  infants 
from  ten  to  thirty  months  old,  although  nurslings  and  adults  are 
also  subject  to  it.  In  spite  of  the  serious  discomforts  which  attend 
the  disease,  and  its  frequent  wide  extent,  it  usually  heals  spon- 
taneously; but  it  may  be  contracted  many  times. 

Treatment. — Considering  that  the  affection  undergoes  spontaneous 
healing,  no  treatment  is  required  except  painting  with  weak  anti- 
septic solutions  (boric  acid,  permanganate  of  potassium,  boro- 
glycerid).  These  remedies  are  applied  to  the  mucous  membrane 
without  the  use  of  force.  When  the  pains  are  severe,  anesthesin, 
orthof orm  or  apothesine  powder  may  be  insufflated  (see  page  270) . 

Chronic  Aphthae  (Aphthae  Tropicae). — Chronic  recurring  aphthae 
are  very  rare.  They  were  first  described  by  Mikulicz.  Small 
epithelial  defects,  the  size  of  a  millet  seed,  or  small  vesicles,  appear 
at  the  lingual  margin  at  intervals  of  four  to  six  weeks.  Within 
four  or  five  days  they  attain  to  the  size  of  a  small  pea.  The  number 
of  these  defects  varies  considerably;  sometimes  there  is  only  one, 
sometimes  two  or  three,  rarely  more.  Their  appearance  is  associ- 
ated with  slight  general  stomatitis  and  salivation.  The  affection 
heals  spontaneously  without  cicatrization;  but  it  frequently  recurs, 
even  before  the  old  foci  have  quite  healed.  The  aphthae  are  very 
sensitive  to  the  touch.  A  very  similar  affection  occurs  in  patients 
suffering  from  "sprue,"  or  chronic  tropical  diarrhea. 

Sprue. — Sprue  or  psilosis  is  a  disease  of  tropical  and  subtropical 
countries  which  renders  the  mucous  membrane  of  the  mouth  and 
tongue  very  sensitive  and  superficially  ulcerated.  That  it  is  of 
infectious  origin  is  shown  by  its  occurrence  in  people  closely  associ- 
ated with  one  another.  Examination  of  the  stools  shows  a  decrease 
or  absence  of  the  digestive  ferments;  the  stools  are  diarrheic,  of  a 
soft,  pasty  and  fermentative  character.  It  is  believed  that  the 
thrush  fungus  (Monilia  Albica)  may  be  the  cause  of  the  condition. 
The  disease  usually  runs  a  chronic  course.  Recent  reports  show 
that  sprue  has  been  treated  successfully  with  emetine  hydrochlorid 
(see  page  723).  The  striking  feature  in  sprue  is  the  persistence 
of  the  complete  absence  of  pancreatic  secretion.  The  pancreatic 
achylia  implies  that  the  administration  of  pancreatic  extract  by 
mouth  is  essential  in  the  treatment  of  the  disease. 


SYPHILIS  OF  THE  MOUTH  309 

Thrush. — This  affection  of  newborn  infants  is  caused  by  the 
thrush  fungus,  a  widely  disseminated  form  of  vegetation  which  is 
found  in  milk  as  well  as  in  the  mouths  of  healthy  nurslings.  In 
the  mouth  it  occurs  as  a  round  or  oval  yeast-like  structure  with 
ramifying  threads.  Healthy  adults  and  nurslings  are  not  affected 
by  this  fungus;  though  it  may  be  present,  they  are  immune.  In 
the  newborn  the  slightest  disorders  of  nutrition  are  sufficient  to 
allow  of  the  pathogenic  development  of  the  thrush  organism.  In 
adults  the  disease  rarely  develops  except  after  protracted  fevers, 
such  as  typhoid.  Thrush  is  at  first  manifested  by  the  appearance 
of  small  white  specks  on  the  mucous  membrane  of  the  cheeks,  gums, 
lips,  and  the  dorsal  surface  of  the  tongue,  which  soon  grow  and  con- 
fiuesce  into  membranous  deposits,  adhering  rather  firmly  to  the 
mucous  membrane.  In  order  to  establish  the  diagnosis,  it  is  neces- 
sary to  wipe  off  a  portion  of  the  deposit  and  examine  it  under  the 
microscope  in  concentrated  solution  of  potash.  If  the  constitutional 
disease  is  not  too  severe,  thrush  remains  confined  to  the  mouth, 
but  in  grave  cases  and  in  unconscious  patients  it  may  spread  to 
the  pharynx  and  esophagus.  In  most  cases  the  growth  is  confined 
to  areas  without  cylindric  epithelium.  It  is  apt  to  penetrate  rather 
deeply  into  the  mucous  membrane. 

Treatment. — The  treatment  is  directed  to  the  underlying  disease; 
the  thrush  will  disappear  as  soon  as  this  is  removed.  It  is  not 
advisable  to  remove  the  coating  mechanically,  since  it  is  situated 
too  deeply  in  the  epithelium  to  admit  of  eradication  in  this  manner. 
Weak  antiseptic  solutions  may  be  used.  For  infants,  boric  acid 
powder  may  be  wrapped  up  in  a  small  bag,  which,  after  having 
been  dipped  into  sugar  or  saccharin,  is  given  them  to  suck. 

SYPHILIS  OF  THE  MOUTH. 

Primary  Syphilis. — The  primary  affection  is  usually  located  on 
the  lower  lip,  at  the  tip  of  the  tongue,  or  at  the  tonsils,  but  it 
has  been  observed  at  other  points  of  the  oral  mucosa.  The  presence 
of  white  triangular  patches  on  the  labial  mucous  membrane  is  often 
indicative  of  syphilis.  It  may  be  assumed  that  the  infection  does 
not  occur  unless  the  syphilitic  virus  is  conveyed  to  lesions  of  the 
mucous  membrane.  This  may  happen  in  various  ways — for  instance 
by  kissing,  by  the  use  of  infected  instruments  (glass-blowers)  or 
eating  and  drinking  utensils,  or  by  unnatural  coitus.  The  primary 
manifestation  in  syphilis  of  the  mouth  (chancre)  develops  in  the 
same  way  as  on  the  genitals.  There  is  a  small  superficial  epithelial 
defect,  with  a  rampart-like  thickening  of  the  margins  and  cartilagi- 
nous hardness  at  the  base.  In  most  cases  there  is  only  one  scle- 
rosed spot;  multiple  sores  are  the  exception.  Should  secondary 
infection  occur,  the  primary  affection  of  the  tonsils  may  lead  to 
deep  ulcers  with  extensive  disintegration.    Of  diagnostic  impor- 


310  DISEASES  OF  THE  MOUTH 

tance  is  the  swelling  of  the  regional  lymph  glands.  In  contrast  with 
the  small  sclerosis,  these  are  often  considerably  swollen,  indurated, 
but  painless.  The  complaints  occasioned  by  the  primary  affection 
are  usually  slight,  but  the  considerable  tension  of  the  soft  parts 
caused  by  the  sclerosis  is  unpleasant.  Swallowing  and  speaking 
are  difficult.  As  a  rule  the  diagnosis  is  not  difficult  except  when 
the  tonsils  are  the  site  of  the  infection  and  induration  is  absent. 
In  doubtful  cases  the  diagnosis  is  made  with  the  aid  of  the  Wasser- 
mann  reaction,  by  exploratory  excision  (when  carcinoma  is  sus- 
pected), and  ex  juvantibus  from  the  effect  of  arphenamine  causing 
rapid  resolution  in  as  short  a  time  as  two  or  three  days.  The 
diagnosis  also  follows  from  the  demonstration  of  the  Treponema 
pallidum  in  the  secretion  of  the  scraped  ulcerous  surface.  The 
primary  affection  heals  without  leaving  any  material  scars. 

Treatment/ — Antisyphilitic  treatment  should  not  be  delayed  after 
the  diagnosis  has  been  established.  It  has  been  generally  believed 
to  be  a  matter  of  indifference  as  regards  the  course  of  the  syphilitic 
infection  whether  treatment  was  instituted  upon  the  appearance  of 
secondary  manifestations  or  at  an  earlier  stage.  More  recent  experi- 
ence, however,  points  to  the  probability  that  very  early  arsphena- 
mine  treatment  (see  page  534)  in  conjunction  with  mercury  is  par- 
ticularly efficacious  and  likely  to  positively  arrest  the  course  of  the 
syphilitic  affection.  From  a  prophylactic  point  of  view  the  atten- 
tion of  the  patients  should  be  directed  to  the  importance  of  pre- 
venting infection  by  kissing  or  by  the  common  use  of  eating  and 
drinking  utensils.  For  local  treatment  the  application  of  calomel 
or  iodoform  is  advisable.  The  swollen  lymph  glands  undergo  rapid 
resolution  when  rubbed  with  mercury  ointment  or  covered  with 
mercury  plaster.  Typical  Hunterian  chancres  are  not  so  common 
as  was  formerly  believed.  The  dark  field  method  of  examination 
has  shown  the  typical  treponemata  in  various  atypical  sores. 

Secondary  Syphilis.— The  secondary  manifestations  occurring  in 
the  mouth  correspond  exactly  to  those  of  the  skin,  but  present 
peculiar  pictures  owing  to  the  soil  upon  which  they  develop.  The 
first  manifestations  of  secondary  oral  syphilis  often  include  an 
erythema  occurring  in  small  or  large  patches  upon  the  oral  mucosa, 
especially  on  the  palate  (angina  erythematosa  luetica).  This 
erythema  usually  disappears  in  a  few  days.  The  most  frequent 
secondary  manifestations  are  the  mucous  plaques  (plaques  opalines), 
consisting  of  circumscribed  infiltrations  of  the  submucosa,  of 
roundish  shape,  which  are  sharply  demarcated  and  raised  flat 
above  the  mucous  membrane.  The  epithelium  above  becomes 
gradually  muddy,  giving  rise  to  the  typical  patches.  These  con- 
sist of  a  grayish-white  thickening  on  the  slightly  swollen  mucosa, 
with  a  hyperemic  marginal  zone,  the  upper  surface  of  which  has 
a  characteristic  pearl-white  to  milk-white  velvety  appearance. 
When  the  plaques  have  persisted  for  a  long  time  they  become 


SYPHILIS  OF  THE  MOUTH  311 

opaque.  As  soon  us  the  muddy  epithelium  becomes  detached, 
flat  defects  of  the  mucous  membrane  with  a  red  or  yellowish  base 
remain  behind.  The  plaques  are  usually  situated  on  the  mucous 
membrane  of  the  lips,  cheeks,  and  tongue,  and,  when  long  per- 
sisting, assume  variable  roundish,  oval  or  other  shapes  and  sizes. 
Their  greatest  extent  is  reached  at  the  palatal  arches.  Occasionally 
the  plaques  will  spread  from  the  lips  to  the  adjacent  skin,  where 
they  form  papules  covered  with  crusts.  ( 'arious  teeth,  the  pressure 
of  artificial  dental  plates,  highly  spiced  food,  alcoholic  beverages, 
and  excessive  smoking,  favor  the  development  of  the  plaques  and 
their  recrudescence.  The  complaints  occasioned  by  the  plaques  are 
often  very  slight  and  again  very  troublesome,  but  in  any  case  the 
plaques  are  most  dangerous  sources  of  infection  for  communicating 
syphilis  to  other  persons.  For  this  reason  the  diagnosis  and  cor- 
responding instructions  to  the  patient  are  of  the  utmost  importance. 
The  diagnosis  of  characteristic  plaques  is  easy,  and  is  supported 
by  the  demonstration  of  syphilitic  skin  eruptions,  glandular  swell- 
ing, the  findings  of  the  Wassermann  test,  and,  if  the  disease  be 
present,  by  the  effect  of  antisyphilitic  medication. 

Treatment. — In  the  first  place,  constitutional  antisyphilitic  treat- 
ment is  required — mercury  for  inunction  or  injection,  and  arsphena- 
mine,  which  apparently  has  an  exceedingly  favorable  and  rapid 
effect  upon  these  syphilitic  affections  of  the  mucous  membrane 
(see  page  534).  For  local  treatment  it  is  advisable  to  touch  the 
plaques  with  a  1-per-cent.  sublimate  solution,  10-  to  20-per-cent. 
silver  nitrate  solution,  5-  to  10-per-cent.  chromic  acid  solution,  or 
the  silver  nitrate  stick.  When  the  plaques  are  very  painful  they 
may  be  powdered  with  anesthesin.  The  above  solutions  are  best 
applied  with  wooden  sticks  tipped  with  cotton,  which  are  to  be 
thrown  away  after  use.  The  argentum  stick  is  contra-indicated  in 
non-syphilitics.  Scrupulous  oral  hygiene,  regular  use  of  mouth- 
washes and  gargles,  and  elimination  of  all  irritations,  form  part  of 
the  treatment  (see  page  296). 

Tertiary  Syphilis. — The  tertiary  processes  in  the  mouth  occur 
at  the  hard  and  the  soft  palate,  at  the  margins  and  dorsum  of  the 
tongue,  less  often  at  the  malar  mucosa  and  lips.  When  the  lips 
are  affected  they  exhibit  circumscribed  gmnmata  which  may 
disintegrate  and  cause  diffuse  inflammatory  infiltration,  with 
considerable  and  firm  swelling  of  the  lips.  Palati  gmnmata, 
which  are  of  very  frequent  occurrence,  may  spread  from  the  hard 
palate  to  the  periosteum,  rapidly  leading  to  necrosis  of  the  thin 
osseous  plate.  The  gumma  of  the  hard  palate  commences  as  a 
small  nodule  which  gradually  becomes  larger  and  softer,  presenting 
a  bluish  discoloration.  It  soon  disintegrates,  the  mucous  mem- 
brane is  perforated,  and  ulcers  of  different  sizes  are  formed  with 
sharp,  coarse  margins  and  a  yellow  lardaceous  base,  exposing  the 
raw  necrotic  bone  beneath.    The  sequestra?  are  separated,  per- 


312  DISEASES  OF  THE  MOUTH 

f orating  the  hard  palate.  As  a  result  there  will  be  a  defect  of 
variable  size  left  in  the  hard  palate  after  healing  has  taken  place. 
The  extent  of  the  destruction  may  be  slight  or  so  great  that  swallow- 
ing and  speaking  are  considerably  interfered  with.  Gummata  of 
the  soft  palate  develop  in  a  similar  way;  they  are  often  multiple 
and  may  also  be  located  on  the  palatal  arches  and  the  uvula. 
The  tongue  is  less  often  involved,  and  in  men  (on  account  of  the 
use  of  alcohol  and  tobacco)  the  lingual  involvement  usually  takes 
the  form  of  sclerotic  glossitis,  with  very  firm  infiltration  and  a 
perfectly  smooth  mucous  surface,  owing  to  complete  loss  of  the 
papillae.  This  form  of  glossitis  is  complicated  by  deep  rhagades 
and  erosions,  usually  at  the  lingual  margins,  which  are  apt  to  give 
rise  to  marked  subjective  symptoms.  After  healing,  they  leave 
calluses  at  the  surface  or  in  the  parenchyma.  The  deeply  situated 
calluses  may  cause  deep  furrows  in  the  tongue.  Lingual  gummata 
may  likewise  occur,  leading  to  considerable  enlargement  of  the 
tongue  and  extensive  ulceration.  The  tertiary  manifestations  of 
the  tongue  may  heal  spontaneously,  but  are  subject  to  frequent 
recrudescences. 

Treatment. — The  specific  constitutional  treatment  is  fully  des- 
cribed in  Chapter  XXVIII.  In  deep  ulcerations  and  bone  necrosis, 
local  treatment  is  necessary  in  the  form  of  iodoform  mass  and 
tamponade  with  iodoform  gauze  (p.  298).  In  glossitis  luetica  it  is 
necessary  to  repair  carious  teeth  and  to  remove  calcareous  deposits. 
Rhagades  are  painted  with  silver  nitrate  or  chromic  acid  solution. 
The  mouth  must  be  rinsed  often  with  antiseptic  washes.  Alcohol 
and  tobacco  are  forbidden.  The  palatal  defects  can  be  repaired  by 
plastic  operation,  as  long  as  they  are  small;  larger  ones  have  to  be 
closed  by  plates. 

In  some  cases  the  salivary  glands  of  the  buccal  fundus  and  those 
at  the  tip  of  the  tongue  show  tertiary  syphilitic  symptoms  in  the 
form  of  swelling  and  enlargement. 

TUBERCULOSIS  OF  THE  MOUTH. 

As  a  rule  the  susceptibility  of  the  oral  mucosa  to  tuberculous 
infection  is  not  great.  Primary  oral  tuberculosis  is  very  rare, 
but  may  be  caused  by  infected  food  (milk),  infected  eating  and 
drinking  utensils,  or  infected  fingers.  The  infection  may  result 
from  the  bovine  as  well  as  from  the  human  type  of  tubercle  bacilli. 
Latterly  the  fact  has  been  emphasized  that  the  bovine  type  plays 
a  far  greater  role  in  the  infection  of  man  than  was  formerly  assumed. 
The  mucous  membrane  of  the  mouth  may  acquire  tuberculosis 
secondarily  by  direct  extension  from  the  facial  skin  or  by  tuber- 
culous sputum. 

Lupus  of  the  Oral  Mucosa. — Lupus  presents  the  same  character- 
istic features  on  the  mucous  membrane  of  the  mouth  as  on  the 


GLANDERS  OF  THE  MOUTH  313 

external  skin.  Points  of  predilection  are  the  free  margins  of  tin- 
lips,  the  vestibulum  oris  at  the  superior  maxilla,  the  palatal  vault, 
and  the  soft  palate.  There  are  at  first  characteristic  nodules, 
which  later  increase  considerably  in  number,  growing  in  close 
proximity.  When  the  epithelium  has  been  lost,  there  appear  flat 
ulcerations  which  may  merge,  the  secretions  drying  up  into  crusts. 
Their  margins  are  lardaceous,  often  undermined,  and  permit  the 
recognition  of  small  nodules.  The  disease  persists  for  a  number  of 
years.  Isolated  parts  may  heal  while  the  pathologic  process  con- 
tinues at  the  margins.  Extensive  destruction  of  the  oral  structures 
may  take  place  in  the  course  of  time  from  this  cause. 

In  tuberculosis  of  the  tongue  there  occur  infiltrations,  rhagades, 
and  ulcerations.  This  affection  has  a  comparatively  favorable 
prognosis.  In  grave  cases  of  tuberculosis  all  parts  of  the  mouth 
are  subject  to  ulcerations  and  miliary  tuberculous  nodules,  with 
simultaneous  infiltration  of  the  deeper  tissue.  Extensive  changes 
of  this  kind  are  found  on  the  tongue  and  lips,  notably  also  in  the 
pharynx  and  on  the  palate  and  tonsils.  The  prognosis  generally  is 
very  unfavorable.  The  discomforts  may  be  slight,  or,  on  the  other 
hand,  very  tormenting,  interfering  with  speech  and  nutrition.  In 
making  the  diagnosis,  this  affection  may  be  mistaken  for  syphilis 
or  carcinoma,  and  in  order  to  clear  up  the  point  it  is  important  to 
demonstrate  tuberculous  changes  in  other  organs  or  tubercle  bacilli 
in  the  pus,  or  apply  the  von  Pirquet  test. 

Treatment. — In  the  absence  of  pronounced  tuberculosis  in  other 
organs,  notably  the  lungs,  energetic  local  treatment  is  indicated. 
Whatever  infiltrations  or  ulcers  lend  themselves  to  extirpation, 
according  to  position,  seat  and  size,  should  be  removed  with  the 
knife  or  the  Paquelin  cautery.  The  after-treatment  consists  in 
applying  iodoform  to  the  wound.  Large  ulcers  and  necrotic  parts 
may  be  tamponed  with  iodoform  gauze.  Great  pain  may  be 
relieved  by  the  local  application  of  orthoform  or  anesthesin  or 
the  administration  of  morphin.  Latterly,  lupus  of  the  mucous 
membrane  of  the  mouth  has  been  treated  with  the  Roentgen  ray 
by  means  of  special  tubes  adapted  to  the  purpose.  This  procedure 
demands  great  caution  in  order  to  prevent  roentgenic  ulcers, 
which  heal  with  great  difficulty.  The  Finsen  light  does  not  act 
so  well  on  lupus  of  the  mucosa  as  on  that  of  the  skin .  Application 
of  sunlight,  and  treatment  with  hot  air,  steam,  and  carbon  dioxid 
snow,  are  new  methods  which  deserve  to  be  tested. 

GLANDERS  OF  THE  MOUTH. 

Malleus. — Glanders  in  man  is  a  very  rare  affection.  The  majority 
of  patients  are  employed  in  handling  horses.  The  disease  may 
run  either  an  acute  or  a  chronic  course.  The  acute  form  results 
from  direct  infection  of  the  blood  current  through  open  wounds, 


314  DISEASES  OF  THE  MOUTH 

causing  infiltrates  which  usually  extend  over  large  areas  of  the  oral 
mucosa.  The  chronic  form  results  from  extension  of  the  infection 
through  the  lymph  current,  starting  from  a  primary  glanderous 
focus  on  the  skin  in  the  neighborhood  of  the  nose  or  mouth.  The 
ulcerations  frequently  attack  the  entire  hard  palate,  sometimes 
involving  the  soft  palate  also.  In  rare  cases  the  affection  extends 
to  the  deep  parts  of  the  upper  lip,  destroying  large  portions,  both 
of  the  lip  and  of  the  nose.  Infiltrations  also  occur  in  the  lower  lip 
and  are  often  accompanied  by  infiltrations  of  the  lymph  glands  of 
the  neck.  The  diagnosis  is  always  difficult  and  cannot  in  all  cases 
be  made  by  mere  inspection  of  the  pathologic  foci.  It  is  important 
to  observe  that,  almost  without  exception,  glanders  of  the  mouth 
is  associated  with  a  similar  eruption  on  the  skin,  which,  however, 
may  have  already  healed.  Actively  proliferating  granulations  are 
always  found  in  the  anterior  part  of  the  nose.  The  glottis  is  often 
involved.  Histologic  examination  of  the  ulcers  shows  simple 
granulation  tissue  without  caseation  of  the  glandular  cells — an 
important  fact  in  differentiating  the  disease  from  tuberculosis. 
Absolute  proof  of  glanders  is,  of  course,  the  demonstration  of 
the  glanders  bacilli,  which  are  best  obtained  from  scraped  super- 
ficial parts  of  the  ulcers  and  granulations,  and  are  demonstrated 
by  intraperitoneal  inoculation  of  guinea-pigs,  the  latter  showing 
typical  glanderous  periorchitis  in  four  or  five  days.  One  reason 
why  a  reliable  diagnosis  is  of  great  importance  is  that  these  patients 
constitute  a  grave  danger  to  others.  The  complaints  are  usually 
slight,  even  in  advanced  cases.  There  is  anorexia  and  lassitude; 
nutrition  is  little  interfered  with,  and  there  is  no  fever.  There  are 
often  septic  complications  or  glanders  pneumonia.  The  prognosis  is 
bad.  The  great  majority  of  cases  terminate  fatally,  the  acute  ones 
always. 

Treatment. — The  ulcers  of  the  mouth  are  treated  locally  in 
accordance  with  general  rules.  The  constitutional  condition  is  said 
to  be  sometimes  favorably  influenced  by  mercury  and  potassium 
iodid.  Serum  therapy  has  not  yet  been  successful,  nor  has  mallein, 
prepared  on  the  principle  of  Koch's  tuberculin.  Vaccines  of  killed 
glanders  bacilli  seem  to  exert  a  favorable  influence  upon  the  con- 
stitutional affection  in  some  cases. 

LEPROSY  OF  THE  MOUTH. 

In  nearly  all  forms  of  leprosy  the  mucous  membrane  of  the 
mouth  becomes  involved — in  the  tuberculous  form,  for  instance, 
in  about  70  per  cent.,  according  to  statistics.  The  involvement 
occurs  at  an  early  stage,  but,  owing  to  the  slight  subjective  symp- 
toms, as  compared  with  the  grave  skin  affection,  is  often  over- 
looked. The  bacteria  of  leprosy  find  a  very  favorable  culture 
ground  in  the  mouth,  where  the  presence  of  lepra  bacilli  can  be 


SCLEROMA  315 

demonstrated  in  larger  numbers  than  anywhere  else.  For  this 
reason,  leprosy  of  the  mouth  gains  in  importance  by  being  an 
easy  source  of  infection  to  others.  The  diagnosis  is  usually  not 
difficult,  because  in  most  cases  the  skin  is  simultaneously  involved. 
The  lepra  bacilli  can  be  demonstrated  by  means  of  the  ordinary 
tubercle  stain.  The  symptoms  occasioned  by  the  oral  affection  are 
strikingly  slight,  large  infiltrations  sometimes  causing  very  little 
inconvenience.  This  is,  as  a  rule,  due  to  the  fact  that  anesthesia 
of  the  affected  parts  occurs  at  an  early  stage.  Salivation  is  often 
excessive.  The  prognosis  is  bad.  A  spontaneous  cure  is  a  rarity. 
Nevertheless,  leprous  infiltrations  may  persist  for  years  without 
increase. 

Treatment. — Ulcerations  often  heal  readily  under  local  treat- 
ment (nitrate  of  silver,  chromic  acid);  internally,  sodium  salicyl- 
ate and  chaulmoogra  oil.  The  latter,  diluted  with  olive  oil  in 
equal  parts,  may  also  be  injected  intramuscularly.  Sodium 
gynocardate,  made  from  the  gynocardic  acid  of  chaulmoogra  oil, 
is  administered  intravenously  with  reported  good  effect.  The 
leprosy  serum  of  Carrasquilla,  lupolin  as  recommended  by  Rost, 
and  the  nastin  of  Deycke  (prepared  from  Streptothrix  leproides) 
have  proved  failures. 

SCLEROMA. 

Scleroma,  a  hardened  patch  or  induration,  prevails  in  Russia 
and  Galicia,  and  is  found  sporadically  throughout  the  world.  It 
seems  to  be  gradually  spreading.  Yon  Frisch's  capsule  bacilli  have 
been  regarded  as  the  cause  of  scleroma,  but  more  recently  the  cap- 
sule bacteria  have  been  found  to  be  identical  wTith  Friedlander's 
pneumonia  bacilli.    They  grow  readily  upon  agar. 

The  affection  is  very  chronic;  it  may  last  for  decades,  the  sub- 
jective symptoms  being  comparatively  slight.  The  diagnosis  may 
be  made  from  observing  the  course  of  the  disease  or  from  demon- 
stration of  the  capsule  bacteria.  The  prognosis  is  very  bad.  Death 
may  result  even  after  many  years  by  continuous  advance  of  the 
process  and  extensive  cicatrization  which  may  occlude  the  entrance 
to  the  esophagus  and  glottis. 

Treatment. — Radical  extirpation  of  the  diseased  parts  may  be 
attempted,  medicinal  treatment  being  a  failure.  The  use  of  the 
Roentgen  ray  has  been  attended  with  favorable  results  in  scleroma 
of  both  nose  and  mouth,  causing  complete  resolution  in  some  cases. 
The  treatment  has  to  be  continued,  however,  for  months  or  years. 
Radium  likewise  seems  to  have  a  favorable  effect.  Application  of 
the  Finsen  light  has  not  been  successful.  Benefit  has  been  observed 
to  follow  accidental  complication  with  erysipelas. 


316  DISEASES  OF  THE  MOUTH 


ACTINOMYCOSIS. 

There  is  no  doubt  that  the  mouth  is  the  most  frequent  port  of 
entrance  for  actinomycosis  in  man,  and  the  disease  is  therefore 
most  frequently  found  in  the  mouth,  throat,  and  glottis.  The 
most  reasonable  explanation  is  that  the  fungus  is  conveyed  to 
the  mouth  by  plants,  possibly  from  using  straws  or  grass  stems 
(from  pastures  where  there  are  diseased  cattle)  as  tooth-picks.  In 
some  cases  the  infection  is  transmitted  directly  from  diseased  cattle. 

In  the  majority  of  cases  the  alveoli  are  attacked  first,  or  there 
may  be  a  periostitic  abscess.  The  fungus  has  also  been  demon- 
strated in  carious  teeth.  Thus  in  man  there  is  a  periostitis  alveo- 
laris,  while  in  animals  there  is  a  central  affection  of  the  inferior 
maxilla.  Though  the  primary  periostitis  heals,  the  disease  con- 
tinues as  an  actinomycotic  tumor  or  a  submaxillary  abscess,  usually 
situated  between  the  inferior  maxilla  and  the  hyoid  bone.  Metas- 
tases are  therefore  often  found  between  the  muscles  and  connective 
tissue  of  the  neck.  The  tonsils,  palatal  arches  and  salivary  glands 
are  not  often  involved  in  man.  The  tongue,  however,  is  often 
affected.  There  are  hard,  sharply  circumscribed  infiltrates,  mostly 
at  the  tip  of  the  tongue,  which  rarely  ulcerate.  These  infiltrates  are 
often  difficult  of  diagnositic  interpretation,  and  it  may  become 
necessary  to  resort  to  an  exploratory  incision  or  excision  to  demon- 
strate the  presence  of  the  fungus.  There  also  seems  to  be  a  pos- 
sibility of  abscess  formation  in  the  tongue,  causing  violent  pain 
and  dyspnea. 

Treatment. — The  pathologic  foci  are  exposed  as  freely  as  possible. 
There  is  no  need,  however,  for  extensive  radical  surgical  measures, 
because  the  prognosis  of  actinomycosis  is  by  no  means  bad,  and 
occasionally  the  affection  even  heals  spontaneously.  The  object 
of  exposure  is  to  disturb  the  fungus,  which  is  anaerobic  in  its  ordinary 
way  of  living.  The  wounds  are  kept  open  by  tampons  of  iodoform 
gauze.  In  acute  suppurative  infiltration,  simple  incision  is  suffi- 
cient. Lingual  tumors  are  best  extirpated.  When  the  course  is 
chronic  and  the  infiltration  considerable,  surgical  intervention  alone 
will  not  suffice.  Good  results  have  been  obtained  with  potassium 
iodid;  1  to  3  Gm.  (15  to  45  grains)  daily  is  administered  internally, 
and  a  5-per-cent.  solution  is  injected  into  the  foci.  It  is  advisable 
to  combine  potassium  iodid  with  the  surgical  treatment. 

SKIN  DISEASES  IN  THE  MOUTH. 

Affections  of  the  mouth  analogous  to  those  of  the  skin  are  caused 
either  by  direct  extension  from  the  latter,  or  as  isolated  affections 
previous  to  the  appearance  of  the  skin  disease,  or  even  without  the 
latter  appearing  at  all. 


SKIN  DISEASES  IN  THE  MOUTH  317 

Eczema.— Eczema  very  often  occurs  on  the  lips.  Scrofulous 
individuals  or  those  with  a  tendency  to  the  formation  of  exudates 
of  various  kinds,  notably  children,  and  persons  harboring  latent 
or  manifest  tuberculosis,  are  predisposed  to  this  affection.  Patients 
of  this  class  very  often  suffer  from  chronic  rhinitis.  The  acrid 
nasal  secretion  easily  leads  to  eczema  around  the  nose,  which 
spreads  directly  to  the  labial  mucosa.  Ulcers  around  the  angles 
of  the  mouth  in  children  should  also  be  classed  as  eczema.  They 
are  exudative  plaques  and  are  covered  with  crusts,  owing  to  con- 
stant scratching  and  licking.  Healing  requires  several  weeks,  and 
there  is  great  tendency  to  recrudescence. 

Treatment. — The  treatment  is  directed  to  the  underlying  cause, 
if  any,  and  to  the  rhinitis.  The  affected  parts  of  the  skin  and 
mucous  membrane,  especially  rhagades,  are  painted  with  a  5-  to 
10-per-cent.  solution  of  silver  nitrate  or  with  mercurial  salve  (white 
precipitate,  1  per  cent.).  Frequent  washing  with  soap  should 
be  avoided;  mouth-washes  containing  volatile  oils  are  rigorously 
contra-indicated.  Arsenic  is  indicated  for  internal  administration. 
A  correction  of  diet,  as  shown  by  the  anaphylactic  food  tests,  is 
productive  of  good  results. 

Lichen  Planus. — Lichen  ruber  planus  occurs  in  characteristic 
form  in  the  mouth.  In  about  50  per  cent,  of  all  skin  cases  the  mouth 
becomes  involved.  There  are  the  well-known  lichen  nodules  of 
the  lips,  malar  mucosa,  tongue,  hard  and  soft  palate.  Their  size 
ranges  from  a  pinhead  to  a  pea;  they  are  whitish,  very  coarse, 
and  grow  in  isolated  groups  forming  circles  or  curves.  Epithelial 
defects  or  considerable  inflammatory  manifestations  are  absent. 
The  affection  causes  practically  no  subjective  symptoms  whatever. 

Treatment. — Lichen  of  the  oral  cavity  is  favorably  influenced  by 
the  internal  or  subcutaneous  use  of  arsenic,  but  more  slowly  than 
the  skin  affection.    There  is  no  need  for  local  treatment. 

Lupus  Erythematosus. — Lupus  erythematosus  is  located  on  the 
nose  and  both  cheeks,  and  can  easily  be  communicated  to  the 
oral  cavity,  and  notably  the  lips.  This  results  in  gray-white 
roundish  plaques,  surrounded  by  a  narrow  blue-red  fringe.  Some- 
times there  are  erosions  partly  covered  with  crusts,  and  loss  of 
epithelium.  The  diagnosis  in  the  presence  of  the  characteristic 
affection  of  the  skin  is  easy.  The  course  of  lupus  erythematosus 
of  the  mucosa  is  just  as  chronic  as  that  of  the  skin. 

Treatment. — The  affection  is  not  readily  influenced  by  medication, 
but  there  is  some  prospect  of  benefit  from  energetically  treating 
the  surface  with  the  Paquelin  cautery.  When  the  lips  are  involved, 
the  application  of  a  highly  concentrated  preparation  of  ichthyol  is 
advisable. 

Pemphigus. — Pemphigus  of  the  skin  very  often  leads  to  involve- 
ment of  the  mucous  membrane  of  the  mouth,  causing  circumscribed 
epithelial    "muddy"    areas   and    white-gray  deposits   resembling 


318  DISEASES  OF  THE  MOUTH 

diphtheritic  membranes.  The  deposits  become  detached  after  having 
persisted  for  a  long  time,  leaving  sharply  demarcated  patches  behind. 
These  may  fuse  and  finally  cover  large  areas,  or  lead  to  erosions 
and  shallow  ulcers.  Pemphigus  of  the  mucous  membrane,  therefore, 
is  not  so  characteristic  as  that  of  the  skin,  for  only  exceptionally  do 
real  vesicles  form  in  the  mouth,  owing  to  its  moisture.  An  isolated 
pemphigus  of  the  oral  mucosa  without  a  corresponding  affection  of 
the  skin  is  very  rare  and,  when  it  occurs,  very  obstinate.  When 
extensive  it  causes  severe  pain,  dysphagia,  and  fetor  ex  ore;  the  entire 
mucosa  may  become  involved  under  certain  circumstances.  The 
participation  of  the  oral  cavity  in  pemphigus  of  the  external  skin  is 
a  very  unfavorable  sign.  The  diagnosis  is  not  difficult  when  cuta- 
neous pemphigus  is  present. 

Treatment. — Healing  rarely  takes  place,  and  treatment  has  but 
little  effect.  Isolated  areas  may  heal  for  a  time,  assisted  perhaps 
by  painting  with  20-per-cent.  silver  nitrate  or  tincture  of  iodin. 
Aside  from  these  measures,  the  treatment  is  confined  to  the  relief 
of  pain  by  painting  with  a  local  anesthetic  solution  (cocain,  eucain, 
or  novocain)  or  by  powdering  with  anesthesin,  orthof orm  or  apothe- 
sine  (see  page  270). 

Erythema  Exudativum  Multiforme. — In  comparison  with  the 
characteristic  cutaneous  manifestations,  those  of  the  mucous  mem- 
brane are  less  distinct.  There  are  roundish  remnants  of  vesicles  in 
the  shape  of  detached  epithelial  shreds  or  easily  bleeding  yellowish 
deposits.  The  affection  is  benign  and  does  not  require  any  par- 
ticular treatment. 

Herpes. — Herpes  zoster  may  occur  at  any  point  in  the  mouth, 
especially  the  cheeks,  pharynx,  or  tongue,  as  well  as  in  the  gums. 
It  is  always  unilateral,  and  manifests  itself  in  vesicles  grouped 
on  the  reddened  and  swollen  mucosa.  The  covering  of  the  vesicles 
is  easily  destroyed.  The  affection  is  associated  with  violent 
neuralgic  pains,  and  recrudescences  are  not  infrequent.  It  may 
occur  in  the  mouth  without  any  simultaneous  affection  of  the  skin. 
The  diagnosis  can  easily  be  made  in  most  cases  from  the  acute 
beginning,  painfulness,  unilateral  occurrence,  and  the  appearance 
of  the  vesicles  as  described.  The  treatment  is  hygienic  (see  page 
296). 

Urticaria. — Urticarial  eruption  in  the  mouth  is  very  rare.  It 
occurs  in  the  form  of  circumscribed,  lustrous,  usually  persistent, 
recurrent  swellings,  without  any  pronounced  inflammation.  Angio- 
neurotic edema  may  likewise  occur  in  the  mouth,  at  the  base  of  the 
tongue. 

Scleroderma. — The  involvement  of  the  mouth  is  comparatively 
rare  and  is  often  overlooked.  There  are  doughy  swellings  and 
indurations  of  the  mucous  membrane,  notably  of  the  tongue. 
High  degrees  of  the  affection  lead  to  ulceration. 


LEUKOPLAKIA  -I") 


LEUKOPLAKIA. 


This  is  an  a  Hit  lion  of  the  mouth  which  is  characterized  by  a 
local  thickening  of  the  epithelium  of  the  mucosa  in  circumscribed 
areas,  due  to  abnormal  cornification.  The  affected  parts  form  a 
kind  of  ridge  resting  upon  a  mucous  membrane- that  is  abundantly 
supplied  with  vessels,  strongly  infiltrated  with  leukocytes,  and  the 
papillae  of  which  are  narrower,  longer  and  more  numerous  than 
normal.  These  ridges  appear  as  smooth,  dry,  milk-white  patches. 
The  most  recent  look  like  mucous  membrane  which  has  been 
painted  with  weak  silver  nitrate  solution.  The  older  the  foci,  the 
stronger  and  firmer  the  ridges,  which  finally  become  a  pure  white  or 
bluish-white,  with  a  kind  of  mother-of-pearl  luster.  The  plaques  are 
sharply  separated  from  the  neighboring  parts,  and  often  surrounded 
by  a  narrow  infiltrated  zone.  Plaques  in  the  various  stages  of 
development  may  be  present  in  the  mouth  at  the  same  time.  Here 
and  there  a  ridge  is  raised  at  the  margins,  and  finally  detached, 
giving  rise  to  rhagades  or  deep  tears.  Leukoplakia  preferably 
invades  the  anterior  part  of  the  dorsal  surface  of  the  tongue, 
especially  toward  the  tip  and  at  the  margins.  There  are  also  foci 
on  the  inner  malar  surface  and  the  lips.  Foci  of  the  palate  and 
alveolar  process  are  very  rare. 

The  disease  runs  a  very  chronic  course,  several  decades  being 
sometimes  required  for  the  originally  tender  epithelial  opacities 
to  develop  into  thick  ridges.  It  is  almost  entirely  confined  to  the 
male  sex  and  rarely  appears  before  the  fortieth  year — as  a  rule 
not  before  the  fiftieth  or  sixtieth.  We  know  now  that  it  is  an 
independent  affection — an  important  discovery  in  view  of  the  fact 
that  formerly  it  was  regarded  as  syphilitic  and  treated  accordingly. 
It  is  positively  not  syphilitic,  although  there  is  no  doubt  that  the 
presence  of  syphilis  predisposes  to  its  development.  Etiologically, 
excessive  smoking  and  the  free  use  of  strong  alcoholic  beverages 
and  highly  spiced  food  are  of  importance;  hence  the  relatively  rare 
occurrence  of  the  disease  in  women.  Gastric  and  intestinal  diseases 
likewise  predispose  to  it. 

Symptoms. — The  complaints  are  not  excessive.  Pain  does  not 
occur  except  in  extensive  rhagades;  otherwise  patients  experience 
a  peculiar  blunted  sensation,  as  if  they  held  a  foreign  body  in  the 
mouth.  For  this  reason  the  tongue  is  constantly  licking  and 
palpating,  thus  mechanically  tearing  off  the  ridges.  These  patients 
are  prone  to  become  hypochondriac,  either  because  they  consider 
the  affection  syphilitic  or  because  they  fear  the  development  of 
carcinoma.  As  a  matter  of  fact,  carcinoma  does  occasionally 
develop  on  the  site  of  leukoplakia;  this  observation  has  been  fre- 
quently made.    But  the  sequence  is,  fortunately,  rather  rare. 

Treatment. — The  exciting  cause  has  to  be  eliminated;  excessive 
smoking,    strong   alcoholic   beverages  and   highly   spiced   dishes 


320  DISEASES  OF  THE  MOUTH 

must  be  avoided.  Defective  teeth  must  be  repaired.  When  the 
inhibition  of  nicotin  cannot  be  enforced,  cigars  or  cigarettes  should 
be  smoked  through  holders.  Chewing  tobacco  is,  of  course,  to  be 
forbidden. 

Light  cases  are  treated  with  mild  mouth-washes,  if  for  no  other 
reason  but  to  pacify  the  patient.  Various  mouth-washes  had  best 
be  used  alternately.  Should  patients  complain  of  troublesome 
burning  sensations,  the  mouth  may  be  rinsed  with  a  decoction  of 
althea  root  or  of  Iceland  moss.  The  plaques  may  be  removed  by 
caustic  agents:  silver  nitrate  either  pure  or  in  a  50-per-cent.  solu- 
tion, 5-  to  10-per-cent.  lactic  acid,  or  30-per-cent.  peroxid  of  hydro- 
gen. Salicylic  acid  acts  as  a  solvent  upon  the  horny  layer;  also 
resorcinol  in  2-per-cent.  solution.  Pure  balsam  of  Peru,  applied  with 
a  brush  and  kept  in  the  mouth  for  two  or  three  minutes,  has  a 
good  effect.  The  alkaline  mineral  waters  have  been  recommended. 
This  medication,  however,  means  failure  in  most  cases,  with  result- 
ing psychic  depression  on  the  part  of  the  patient,  especially  when 
the  oral  condition  is  painful  and  there  is  trouble  in  eating,  drinking, 
and  speaking.  In  these  cases  surgical  measures  may  be  attempted 
as  a  final  resort.     Radiuni  has  proved  of  great  value. 

Many  authors  suggest  antisyphilitic  treatment,  and  in  some  cases 
energetic  mercurial  medication  has  resulted  in  complete  cure. 
Latterly,  arsphenamine  has  been  warmly  recommended.  Anti- 
syphilitic  treatment  is  certainly  indicated  unless  there  are  reasons 
to  the  contrary. 

ANIMAL  PARASITES  IN  THE  MOUTH. 

Larvse  of  flies,  cysticerci  and  echinococci  have  been  found  in 
the  mouth,  and  trichinae  in  the  tongue. 

NERVOUS  AFFECTIONS  OF  THE  MOUTH. 

Paralysis  of  the  Facial  Nerve. — Paralysis  of  the  facial  nerve 
often  induces  an  oblique  position  of  the  palate;  the  troublesome 
flow  of  saliva  is  due  to  the  paralyzed  angle  of  the  mouth  being 
constantly  open.  Injuries  to  the  hypoglossal  nerve  lead  to  par- 
alysis of  the  lingual  musculature.  There  are  to  be  distinguished: 
Total  glossoplegia,  glossoplegia  interna  (longitudinal  and  trans- 
verse lingual  muscles),  and  glossoplegia  externa  (geniohyo-,  stylo-, 
hyo-,  palato-  and  chondro-glossus  muscles) .  Some  lingual  muscles 
are,  occasionally,  paralyzed  by  neuritis,  as  after  diphtheria.  Con- 
vulsions of  the  hyoid  musculature  may  easily  occur,  especially 
in  epileptics,  causing  the  tongue  to  be  bitten.  Isolated  clonic  and 
tonic  spasms  are  observed  in  hysteria.  Tonic  spasms  are  also  met 
with  in  tetanus,   rabies,  hemiplegia,   and  hemiparalysis  agitans. 


VASOMOTOR,   TROPHIC  AND  SECRETORY  DISORDERS     321 

Clonic  spasms  occur  in  cortical  affections  of  the  brain,  chorea, 
myotonia  congenita,  and  paramyoclonus  multiplex.  Occupation 
spasms  of  the  tongue  have  also  been  observed.  Ataxia  of  the 
tongue  occurs  in  tabes.  Permanent  contractures  of  the  geniohyo- 
glossus  and  styloglossus  muscles  occur  in  hysteria. 

Disorders  of  sensation  are  usually  found  together  with  similar 
disorders  in  other  trigeminal  regions.  Anesthesia  is  usually  con- 
fined to  one  half  of  the  tongue  and  is  often  not  discovered  by  the 
patient.  Disorders  of  the  sense  of  taste  due  to  lesions  of  the  chorda 
tympani  are  confined  to  the  anterior  part  of  the  lingual  margin. 
Affections  of  the  glossopharyngeal  nerve  impair  the  sense  of  taste 
in  the  posterior  part  of  the  tongue. 

By  neuralgia  of  the  tongue  is  distinctly  understood  neuralgia 
of  the  lingual  nerve  which  represents  a  special  form  of  the  genuine 
trigeminal  neuralgia.  This  is  accompanied  by  typical  paroxysms 
of  pain,  both  spontaneously  and  upon  extraneous  irritation.  The 
neuralgia  is  rarely  confined  to  the  lingual  nerve;  as  a  rule  there  is 
also  neuralgia  of  the  inferior  maxillary.  Neuralgic  pain  in  the 
region  of  the  lingual  nerve  should  always  suggest  local  affections 
of  the  tongue,  especially  carcinoma. 

Treatment.— The  treatment  corresponds  to  that  of  trigeminal  neu- 
ralgia. Locally,  the  galvanic  current  may  be  tried,  or,  if  necessary, 
resection  of  the  lingual  nerve. 

Glossodynia. — Glossodynia  comprises  indefinable  painful  sensa- 
tions in  the  tongue  which  may  torment  the  patient  for  hours  or 
days.  It  is  a  condition,  therefore,  which  differs  absolutely  from 
neuralgia.  Patients  complain  of  all  kinds  of  painful  sensations 
in  the  tongue,  for  which  they  call  in  the  physician.  In  most  cases 
they  are  hypochondriacs  who  are  apprehensive  of  lingual  carcinoma 
and  syphilis.  Deglutition  is  not  impaired.  They  are  able  to  eat 
well,  and  during  eating  forget  their  complaints. 

Treatment. — The  treatment  should  be  psychic.  No  local  treat- 
ment is  indicated. 


VASOMOTOR,  TROPHIC  AND  SECRETORY  DISORDERS. 

In  tabes  and  syringomyelia  there  are  ulcers  of  the  alveolar 
process  and  hard  palate  (mal  perforant  buccal).  In  Raynaud's  dis- 
ease, angiospasm  occurs  in  the  tongue  by  way  of  exception.  Reflex 
salivation  occurs  in  hysteric  and  neurasthenic  patients  following 
painful  affections  of  the  mouth.  Decreased  salivation  occurs  in 
acute  febrile  affections,  likewise  in  hysteria  and  paralysis  of  the 
sympathetic.  Total  arrest  of  salivation,  called  xerostomia,  is  a 
tormenting,  painful  condition,  causing  difficulty  in  swallowing  and 
speaking.  Absolute  toothlessness  seems  capable  of  causing  it.  In 
some  cases  pilocarpin  has  proved  useful. 
21 


322  DISEASES  OF  THE  MOUTH 

AFFECTIONS  OF  THE  TONGUE. 

Malformation. — It  occasionally  happens  that  the  thyroglossal 
duct  remains  patent,  causing  the  base  of  the  tongue  to  swell  from 
congested  secretion.  This  condition  requires  surgical  intervention. 
The  formation  of  cysts  in  the  duct  is  also  possible.  Adhesion  of 
the  tongue  to  the  palatal  fundus  likewise  occurs.  A  short  frenum 
linguae  is  no  malformation,  and  the  incision  of  the  same  which  is 
frequently  practiced  is  superfluous  and  objectionable.  Disorders 
of  speech  are  never  improved  by  this  operation. 

Coating  or  Furring. — A  coated  tongue  is  observed  either  as  an 
independent  affection  (glossitis)  in  the  course  of  stomatitis,  or  as  a 
result  of  constitutional  or  organic  affections  impairing  the  digestion 
of  food.  As  soon  as  mastication  and  deglutition  are  interfered  with, 
the  automatic  self-cleansing  of  the  mouth,  which  even  careful  oral 
hygiene  cannot  replace,  fails;  the  tongue  becomes  coated,  which 
means  that  desquamated  epithelial  masses  and  other  debris  remain 
there.  Considerable  cornification  of  the  papilla?  filiformes  of  the 
lingual  epithelium  sets  in,  accompanied  by  light  inflammatory 
manifestations  (hyperemia  of  the  papilla?)  as  a  consequence  of 
defective  mastication  and  deglutition.  The  coating  of  the  tongue 
consists  of  cornified,  desquamated  epithelia,  desquamated  tips  of 
papilla?,  leukocytes,  mucus,  lime  and  cholesterol  crystals,  bacteria, 
mycelia,  food  remnants,  and  a  brownish  coloring  substance.  The 
coating  usually  is  yellowish-white  to  yellowish-brown.  Colored 
articles  of  food  (red  wine,  blackberries,  cocoa,  etc.)  often  render 
the  color  intense. 

Coating  of  the  tongue  occurs  not  only  in  grave  febrile  constitu- 
tional diseases  (typhoid,  sepsis,  etc.),  but  in  all  conditions  in  which 
mastication  and  deglutition  are  impaired  (hemiplegia,  gastro- 
intestinal affections,  etc.).  The  appearance  of  a  coated  tongue 
is  sometimes,  but  by  no  means  always,  a  sign  of  poor  appetite  and 
nutrition.  When  there  is  no  disorder  of  the  general  condition,  a 
coated  tongue  must  be  regarded  as  an  isolated  catarrh  of  the  tongue 
(glossitis) . 

If  patients  keep  their  mouths  continually  open  in  the  course 
of  the  affections  mentioned,  the  cavity  will  become  dry  and  the 
coating  of  the  tongue  turn  brown.  The  surface  of  the  tongue  may 
become  fissured  and  fragile,  and  slight  hemorrhages  tend  to  impart 
a  pronounced  brown  color  to  the  coating. 

Treatment. — Deodorizing  and  weak  antiseptic  mouth-washes, 
to  modify  and  remove  the  coating,  should  be  used,  but  no  highly 
astringent  or  caustic  agents.  Exaggerated  mechanical  cleansing 
of  the  tongue  by  scraping  or  brushing  is  usually  unnecessary  and 
not  apt  to  improve  conditions  for  any  length  of  time.  In  constitu- 
tional diseases,  proper  oral  hygiene  may  prevent  the  occurrence 
or  increase  of  the  coating  (see  page  296) . 


AFFECTIONS  OF  THE  TONGUE  323 

Lingua  Geographica. — The  geographic  tongue   is  an   affection 

of  childhood  and  occurs  until  the  advent  of  puberty.  It  is  rare  in 
later  years.  There  are  round,  intensely  red  plaques  on  the  tongue 
which  vary  in  form  and  size  and  are  often  protruding.  There  is 
often  a  sharply  demarcated  gray  marginal  zone  consisting  of 
small,  dense  gray  patches — enlarged  papilla?  filiformes  with  thick- 
ened epithelium.  The  papillae  fungiformes  are  likewise  thickened, 
enlarged,  and  intensely  red.  A  characteristic  sign  of  these  plaques 
is  their  inconstancy.  They  are  capable  of  considerably  changing 
their  size  and  form  within  a  short  time;  they  blend  or  disappear, 
while  new  ones  appear  in  other  places.  Occasionally  there  is  simul- 
taneous diffuse  stomatitis.  In  other  cases  rhagades  are  formed 
which  may  cause  pain,  while  the  affection  otherwise  gives  rise  to  no 
complaints.  Attention  has  latterly  been  called  to  the  fact  that 
this  affection  is  very  often  met  with  in  children  with  an  exudative 
diathesis,  from  which  the  conclusion  has  been  drawm  that  the 
measures  employed  for  the  improvement  of  this  diathesis  and  other 
disorders  of  nutrition  in  childhood  are  apt  to  modify  or  remove 
this  affection.  It  may  occur  as  a  family  affection,  and  is  often 
congenital.  Microorganisms  have  so  far  not  been  discovered  as 
exciting  factors.  The  geographic  tongue  is  not  infrequently  found 
in  nurslings.  It  is  a  permanent  affection  in  that  it  persists  imtil 
puberty,  when  it  disappears.  It  is  thoroughly  benign  and  has 
nothing  to  do  with  syphilis,  though  such  a  relation  is  often  assumed. 
Treatment. — The  affection  itself  requires  no  treatment,  but  any 
coincident  or  causative  disorders  of  nutrition  or  tendency  to  exuda- 
tion should  be  treated.  Careful  dental  hygiene  is  of  the  greatest 
importance  (see  page  294). 

Hair-tongue  (Lingua  nigra). — This  affection  is  always  located 
on  that  part  of  the  dorsal  surface  of  the  tongue  which  is  situated 
immediately  in  front  of  the  papilla?  vallatse.  At  this  spot  there 
is  a  peculiar  discoloration,  of  varying  hue  and  intensity;  yellow, 
brown,  black  and  green  hair-tongues  have  been  described.  The 
affection  is  found  in  an  irregular,  oval  or  triangular  area.  Its 
peculiar  appearance  is  due  to  the  fact  that  the  papilla?  filiformes 
are  considerably  elongated  and  thickened,  and  occasionally  assume 
the  appearance  of  bristly  thick  hairs.  Stomatitis  and  excessive 
smoking  seem  to  be  capable  of  causing  it.  The  black  or  brown 
color  is  due  to  the  cornified  epithelia.  The  affection  causes  no  dis- 
comfort in  the  mouth  except  a  mushy  sensation  and  a  stale  acidulous 
taste.  The  patients,  however,  often  suffer  from  gastro-intestinal 
disturbances.    The  duration  of  the  condition  varies. 

Treatment. — Treatment  is  really  unnecessary.  To  soften  the 
cornified  masses,  salicylic  acid,  resorcinol  and  hydrogen  peroxid 
are  useful.  The  affected  parts  may,  if  necessary,  be  first  scraped. 
It  should  be  remembered  that  cases  have  occurred  of  hair-tongues 
making  their  first  appearance  after  the  use  of  hydrogen  peroxid. 


324  DISEASES  OF  THE  MOUTH 

PHLEGMONOUS  PROCESSES  OF  THE  TONGUE. 

These  occur  in  the  form  of  superficial  or  deep  abscesses  or  diffuse 
inflammation  of  the  lingual  substance  (glossitis  acuta  diffusa) . 

Abscess. — The  usual  seat  of  lingual  abscesses  is  at  the  dorsal 
surface  of  the  tongue,  toward  the  base.  They  originate  from 
bacteria  in  the  mucous  glands  and  follicles  of  the  tongue  or  from 
small  foreign  bodies  which  have  penetrated  into  the  tongue.  The 
abscesses  develop  gradually,  usually  with  an  accompaniment  of 
moderate  pain.  The  swelling  of  the  affected  part  interferes  with 
swallowing  and  speaking.  As  a  rule  the  abscesses  are  situated  in 
one  side,  rarely  in  the  middle  of  the  tongue.  They  may  attain  to 
a  considerable  size,  and  can  be  diagnosed  from  the  tense  condition 
and  the  sensation  of  fluctuation. 

Treatment. — Incision  and  evacuation  of  pus  will  lead  to  a  prompt 
cure. 

Acute  Diffused  Glossitis. — Deep  phlegmons  of  the  tongue  are 
rare,  and  occur  in  the  wake  of  grave  stomatitis  (mercurial)  and 
of  infectious  constitutional  diseases  (typhoid,  erysipelas,  variola, 
anthrax,  etc.).  Insect  bites  and  penetrating  foreign  bodies  may 
likewise  cause  phlegmons  of  the  tongue.  Among  the  symptoms  are 
high  fever  and  considerable  swelling  of  the  tongue,  which  may 
reach  such  proportions  that  the  mouth  is  too  small  to  hold  it. 
There  are  violent  pains,  radiating  into  the  ear.  The  surface  of  the 
tongue  is  dark  violet  or  bluish-red.  The  edema  may  extend  to 
the  fauces,  palatal  arches,  and  entrance  to  the  glottis.  The  affec- 
tion is  always  a  very  severe  and  serious  one,  especially  because 
there  is  danger  of  general  pyemia  with  fatal  issue.  On  the  other 
hand,  the  inflammatory  processes  may  spontaneously  disappear. 
An  abscess  in  the  deep  tissues  of  the  tongue  affords  better  oppor- 
tunity for  successful  treatment  than  one  that  is  superficially  located. 
Abscesses  are  readily  formed  in  the  loose  connective  tissue  between 
the  geniohyoglossus,  hylohyoid  and  hyoglossus  muscles.  No  doubt 
it  is  often  exceedingly  difficult  to  recognize  a  deep  abscess;  indeed, 
this  may  be  impossible  without  exploratory  puncture  and  incision. 
Chronic  deep  lingual  abscesses  are  said  to  occur  which  run  a  very 
slow  course,  with  comparatively  favorable  prognosis. 

Treatment. — If  the  initial  course  of  the  affection  is  mild  enough 
to  justify  the  assumption  that  no  abscess  will  be  formed,  the  treat- 
ment may  be  confined  to  the  application  of  ice  and  cooling  antiseptic 
mouth-washes.  The  same  treatment  would  be  indicated  in  hopeless 
cases  (anthrax).  In  grave  cases  and  in  the  presence  of  dyspnea, 
tracheotomy  is  advisable  in  order  to  prevent  sudden  suffocation. 
If  an  abscess  is  probable,  the  therapeutic  endeavors  should  be 
directed  to  opening  it  with  all  available  means.  Evacuation  of  the 
abscess  materially  improves  the  prognosis,  as  it  tends  to  rapidly 
reduce  the  inflammation.     The  incision  is  to  be  kept  open.     In 


PHLEGMONOUS  PROCESSES  OF  THE  TONGUE  325 

the  absence  of  an  abscess,  scarification  of  the  tongue  Longitudinally 
may  be  effected  in  serious  cases.  The  wound  fissures  are  tamponed 
with  iodoform  gauze  or  rubbed  with  iodoform  mass  (page  298). 
Hemorrhage,  which  is  usually  considerable,  is  soon  arrested. 

Decubital  Ulcer  of  the  Tongue. — When  the  tongue  is  exposed 
to  constant  friction  by  carious  or  inward  growing  teeth,  or  by 
sharp  edges  and  rough  places,  its  exposed  part  is  deprived  of  epithe- 
lium, and  the  underlying  tissues  undergo  inflammatory  induration. 
There  is  at  first  a  small  nodule,  painful  during  speech  or  mastica- 
tion, which  gradually  grows  and  may  reach  the  size  of  a  hazelnut. 
With  increase  in  size  the  painfullness  increases.  The  surface  of  the 
nodule  may  disintegrate,  forming  an  ulcer.  Both  induration  and 
ulcer  may  heal  spontaneously  when  the  roughness  has  been  polished 
off  by  the  tongue.  The  affection  itself  is  harmless,  but,  as  it  may 
be  mistaken  for  carcinoma,  its  diagnosis  is  important.  Indeed, 
neglected  decubital  ulcers  of  this  kind  may  occasionally  develop  into 
carcinoma.  The  diagnosis  is  very  easy  in  view  of  the  pronounced 
tendency  of  decubital  ulcers  to  heal  after  the  offending  tooth  or 
other  exciting  cause  has  been  removed. 

Treatment. — Irregularities  of  the  teeth,  if  any,  are  corrected,  or 
the  offending  teeth  extracted.  The  ulcer  heals  in  from  eight  to  ten 
days. 

Chronic  Superficial  Glossitis. — Moeller,  in  1851,  was  the  first 
to  describe  this  affection.  It  is  a  peculiar  inflammation  of  the 
lingual  surface,  occurring  mostly  in  females.  There  are  severe 
burning  pains  which  may  become  insupportable  in  mastication  or 
prolonged  speaking,  and  irregularly  disseminated  red  patches 
and  striae  on  the  dorsal  aspect  of  the  tongue  and  especially  at  the 
tip.  The  epithelium  around  the  patches  is  very  thin  or  slightly 
defective,  and  the  mucous  membrane  underneath  shows  small- 
celled  infiltration.  The  papillae  in  the  area  of  the  inflamed  parts 
are  often  hyperemia  The  foci  are,  as  a  rule,  found  on  the  dorsal 
surface  of  the  tongue,  at  the  tip  and  the  lateral  margins,  the  other 
parts  appearing  normal.  The  pains  are  strikingly  severe,  consider- 
ing the  slight  anatomic  changes — so  much  so  that  ingestion  of  food 
may  have  to  be  restricted  to  the  utmost.  Should  this  occur  in 
undernourished  patients,  severe  disorders  of  nutrition  may  follow. 
The  course  is  very  chronic.  The  affection  develops  in  sudden  spurts, 
alternating  with  comparatively  quiescent  periods  lasting  for  weeks 
or  months.     In  this  way  it  may  persist  for  years. 

Treatment. — Painting  of  the  affected  parts  with  silver  nitrate 
and  lactic  acid  has  sometimes  proved  beneficial.  Rinsing  with 
a  blackberry  decoction,  and  restriction  to  a  salt-free  and  non- 
albmninous  diet,  have  been  recommended. 

Acute  Papular  Glossitis. — All  the  cases  of  this  rare  affection  so 
far  described  have  occurred  in  women.  It  seems  to  commence  with 
slight  febrile  manifestations,  lassitude  and  anorexia,  followed  by 


326  DISEASES  OF  THE  MOUTH 

burning  pains  in  the  tongue  and  the  formation  of  isolated  white 
patches  on  its  surface  the  size  of  a  pea.  These  patches  become 
erosions  with  red  and  serrated  edges,  the  base  covered  with  pus. 
The  affection  seems  to  heal  spontaneously,  after  having  continued 
for  about  three  weeks.  Nothing  is  known  as  to  its  etiology.  The 
foci  resemble,  to  a  certain  extent,  variolar  and  varicellar  pustules. 

Treatment. — Oral  hygiene,  antiseptic  mouth -washes  (page  296). 

Macroglossia. — Abnormal  enlargement  of  the  tongue  occurs  con- 
genially, its  development  in  childhood  or  later  being  rare.  The 
enlargement  may  attain  to  the  proportions  of  elephantiasis.  Macro- 
glossia is  usually  due  to  lymphangioma,  although  there  is  also 
a  muscular  form  in  which  the  tongue  attains  to  twice  or  three 
times  its  normal  size,  or  it  may  acquire  abnormal  length,  though 
covered  by  normal  mucous  membrane.  This  form  is  always  con- 
genital. Ingestion  of  food  being  hindered,  operative  intervention 
in  the  shape  of  cuneiform  excisions  may  be  necessary.  Ligation  of 
the  lingual  artery  has  also  been  recommended.  Macroglossia  is 
sometimes  a  manifestation  of  general  acromegaly.  The  lymphan-" 
giomatous  form  is  also  found  in  cretinism. 

Lingua  Plicata. — Related  to  congenital  macroglossia  is  the 
furrowed  tongue.  The  tongue  is  enlarged,  though  not  extremely; 
its  shape  is  approximately  normal,  but  its  surface  is  covered  with 
numerous  symmetrically  arranged  furrows,  the  deepest  being  in 
the  median  line.  The  prominent  parts  have  normal  papillae,  while 
in  the  furrows  there  are  none.  Neurasthenic  individuals  may 
suffer  much  inconvenience  and  pain  from  this  condition.  The 
plicated  tongue  not  infrequently  develops  into  the  geographic  form 
(page  325). 

AFFECTIONS  OF  THE  LINGUAL  TONSIL. 

The  follicular  structures  at  the  base  of  the  tongue  are  called 
lingual  tonsils. ' 

Acute,  Lingual  Tonsillitis. — This  acute  inflammation  frequently 
occurs  in  inflammation  of  the  palate  and  parenchymatous  tonsil- 
litis. The  follicles  are  reddened  and  the  region  of  the  lingual  tonsil 
is  swollen.    There  is  no  need  for  special  treatment. 

Hypertrophy  of  the  Lingual  Tonsil. — The  swelling  affects  either 
isolated  follicles  or  the  entire  tonsil,  the  superficial  veins  being 
varicosely  dilated.  These  veins  may  even  burst  during  coughing 
or  vomiting,  giving  rise  to  an  alarming  though  harmless  hemorrhage. 
The  hypertrophy  is  apt  to  impart  a  guttural  sound  to  the  speech, 
interfere  with  singing,  and  cause  fatigue  and  cough.  It  also  gives 
rise  to  a  feeling  of  oppression  in  the  mouth,  simulating  the  presence 
of  a  foreign  body. 

Treatment. — Cauterizing  agents  and  similar  remedies  are  usually 
unsuccessful.  Should  energetic  measures  be  indicated,  the  entire 
hypertrophic  tonsil  should  be  ablated. 


DISEASES  OF  THE  SALIVARY  DUCTS  327 

Hyperkeratosis. — This  affection  is  often  located  on  the  hyperemic 
lingua]  tonsil  and  is  an  abnormal  process  of  cornification,  forming 
in  the  crypts  of  the  lingual  tonsil  hard  hair-like  cones  which  may 
protrude  from  the  crypts  like  hairs  and  can  be  removed  with  forceps. 
Often  there  is  no  subjective  sensation  whatever  except  scratching 
and  pressure,  and  occasionally  an  unpleasant,  putrescent  taste  in 
the  mouth. 

Treatment. — The  affection  often  disappears  spontaneously,  and 
requires  no  treatment  unless  the  symptoms  are  severe.  If  any 
eradicative  measures  are  resorted  to,  they  should  be  energetic — 
curetting  and  the  Paquelin  cautery. 

DISEASES  OF  THE  SALIVARY  DUCTS. 

Sialodochitis.  —  Inflammation  of  the  excretory  ducts  of  the 
salivary  glands  may  be  due  to  invasion  by  bacteria  or  the  introduc- 
tion of  foreign  bodies  into  the  excretory  ducts.  The  submaxillary 
duct  is  most  subject  to  attack;  it  terminates  in  an  aperture  at 
the  salivary  caruncle  which  is  permeable  by  a  thin  sound,  while 
immediately  below  the  aperture  it  is  conically  enlarged,  and  beyond 
this  again,  for  two-thirds  of  its  extent,  it  is  narrower.  Foreign 
bodies  are  therefore  apt  to  be  arrested  at  the  anterior  enlargement 
of  the  duct. 

The  sublingual  gland  usually  terminates  in  several  short  ducts, 
thus  offering  difficulties  to  the  entrance  of  foreign  bodies.  The 
terminations  of  the  anterior  lingual  glands  present  a  similar  struc- 
ture. The  aperture  of  the  parotid  duct  is  comparatively  large,  but, 
as  there  is  a  decided  curve  immediately  behind  it,  foreign  bodies  are 
hindered  from  entering. 

Inflammation  will  result  either  when  foreign  bodies  are  arrested 
in  one  of  the  ducts  or  when  there  is  a  bacterial  infection  without 
foreign  bodies.  The  ducts  then  exude  a  purulent  secretion  which 
can  be  expressed  between  the  fingers;  later  on,  a  large  quantity 
of  viscid  saliva  may  often  be  evacuated  which  has  probably  been 
retained  in  the  ducts  by  swelling  of  the  mucous  membrane.  Fre- 
quently there  is  periodic  spontaneous  evacuation,  as,  for  instance, 
while  eating,  or  even  at  the  mere  sight  of  food.  This  may  be 
accompanied  by  severe  pain  in  the  buccal  fundus  (coliques  sali- 
vaires),  and  occasionally  by  a  disturbance  of  the  general  condition, 
chills  and  fever.  These  painful  paroxysms  often  occur  at  long 
intervals,  but,  later,  follow  in  more  rapid  succession.  Finally  the 
evacuation  of  pus  occurs  during  the  painless  intervals  also  (pyorrhea 
salivaris) . 

Sialoliths. — Impacted  foreign  bodies  may  develop  into  salivary 
calculi  by  incrustation,  but  these  may  also  be  formed  without  the 
presence  of  foreign  bodies.  In  any  case,  the  formation  of  stones 
can  occur  only  in  the  presence  of  sialodochitis.     Stones  are  least 


328  DISEASES  OF  THE  MOUTH 

frequently  formed  in  the  parotid  and  sublingual  ducts.  The  sub- 
maxillary duct  is  most  often  affected.  The  stones  are  located 
1  or  2  centimeters  behind  the  sublingual  caruncle,  and  are  elongated, 
pear-shaped,  or,  less  often,  round.  They  vary  in  size  from  a  grain 
of  wheat  to  a  date  kernel,  but  may  in  exceptional  cases  become 
much  larger;  stones  the  size  of  a  hen's  egg  have  been  observed.  In 
most  cases  they  are  grayish-white  and  of  mortar-like  consistency, 
though  sometimes  they  are  harder  and  darker.  They  consist  of 
calcium  phosphate,  less  often  of  calcium  carbonate.  Should  there 
be  any  marked  inflammation  at  the  same  time,  the  walls  of  the 
distended  salivarj^  duct  may  be  destroyed  by  ulceration,  thus 
embedding  the  stones  in  an  abscess.  The  circumstances  may  be 
such  that  the  pus  perforates  outward,  causing  the  formation  of  a 
fistula  which  will  not  close  until  the  stones  are  removed. 

Symptoms. — The  symptoms  of  salivary  calculi  resemble  those 
of  simple  inflammation  and  foreign  bodies  in  the  duct,  and  con- 
sist of  pyorrhea,  swelling  in  the  vicinity  of  the  duct  and  the  glands 
appertaining  thereto,  and  pain.  The  diagnosis  is  made  with  the 
sound  and  is  particularly  easy  in  the  submaxillary  duct.  Stones 
in  the  parotid  duct  may  have  to  be  demonstrated  by  bimanual  pal- 
pation. Pathologic  thickening  of  the  floor  of  the  mouth  should 
always  raise  the  suspicion  of  salivary  calculi.  Their  presence  is 
sometimes  revealed  by  the  Roentgen  ray  (see  Plate  XXII,  Fig.  4) .  . 

Treatment. — If  possible  the  stone  should  be  removed,  and  this 
can  in  nearly  all  cases  be  done  under  local  anesthesia.  If  the  stone 
is  embedded  in  an  abscess,  it  can  be  easily  removed  after  incision 
of  the  latter.  If  the  stone  cannot  be  detected  after  incision  of  the 
duct,  it  may  be  expelled  spontaneously  after  a  few  days.  Should  a 
stone  lie  in  the  gland  itself,  the  gland  had  better  be  extirpated  in 
toto. 

DISEASES  OF  THE  SALIVARY  GLANDS. 

Secondary  Sialadenitis  in  Affections  of  the  Salivary  Ducts. — 

If  sialodochitis  has  developed  from  foreign  bodies,  infection,  or 
salivary  stones,  the  salivary  glands  affected  frequently  undergo 
rapid  swelling.  The  skin  over  the  gland  is  hyper emic  and  sensitive, 
but  the  swelling  usually  subsides  promptly  without  causing  an 
abscess.  Should  this  occur  often,  it  will  lead  to  dilatation,  indura- 
tion, and  slight  painfulness  of  the  gland  from  inflammatory  infil- 
tration of  the  glandular  connective  tissue,  accompanied  by  slight 
pain  in  deglutition  both  in  the  throat  and  in  the  region  of  the  gland. 
On  the  other  hand,  the  whole  trouble  sometimes  rapidly  disappears, 
even  after  repeated  swelling  of  the  gland. 

Treatment. — Bimanual  massage  of  the  glands,  painting  with  iodin, 
and  the  administration  of  salicylic  preparations  are  advisable. 
Should  dilatation  and  painfulness  persist,  the  gland  should  be 
extirpated. 


DISEASES  OF  THE  SALIVARY  GLANDS  329 

Salivary  calculi  in  the  glands  are  usually  multiple,  and  from  the 
size  of  a  millet  seed  to  that  of  a  pea.  Should  they  persist  until 
the  gland  is  chronically  affected,  the  latter  should  he  extirpated. 

Diseases  of  the  Salivary  Glands  in  General  Affections. — The 
salivary  glands,  especially  the  parotid,  are  usually  involved  when 
the  patient  is  suffering  from  septic  affections  and  grave  infectious 
diseases  (scarlatina,  measles,  variola,  typhoid).  Suppurative  inflam- 
mation in  these  conditions  is  prognostic-ally  unfavorable;  it  usually 
leads  to  an  abscess  which  has  to  be  incised,  preferably  from  without. 
Ulcerous  parotitis  not  infrequently  leads  to  general  septic  infection. 
Inflammatory  changes  in  the  salivary  glands  are  always  present  in 
rabies. 

Inflammation  of  the  salivary  ducts  after  surgical  operations  is 
likewise  a  prognostically  unfavorable  condition.  Probably  it  origi- 
nates in  the  mouth,  especially  when  the  amount  of  ingested  food 
has  been  small  and  the  mouth  is  poorly  cleansed.  Here,  again, 
an  abscess  is  liable  to  develop,  leading  to  general  sepsis. 

There  are  also  inflammations  of  the  salivary  glands  without 
septic  or  infectious  general  disease  and  without  involvement  of 
the  salivary  ducts,  in  both  adults  and  children.  In  adults  the 
parotid  is  often  involved,  in  ehildren  the  submaxillary  gland. 
These  glandular  affections  are  often  symmetric  and  accompanied 
by  moderate  pain,  slight  elevation  of  temperature,  swelling  of  the 
glands,  and  some  disturbance  of  the  general  condition;  they  may 
also  lead  to  abscess.  Nothing  definite  is  known  in  regard  to  their 
etiology. 

Actinomycosis,  Syphilis,  Tuberculosis. — Actinomycosis  of  the  sali- 
vary glands  is  rare  as  a  primary  affection,  while  as  a  secondary 
involvement  in  actinomycosis  of  the  oral  cavity  it  is  more  frequent. 
Syphilis  of  the  salivary  glands  occurs  in  the  form  of  gummatous 
enlargement  of  the  affected  glands,  but  up  to  the  present  it  has 
been  observed  only  in  the  sublingual  and  anterior  lingual  glands. 
Tuberculosis,  as  a  rule,  affects  only  the  parotid  gland. 

Epidemic  Parotitis. — This  is  the  result  of  a  contagious  affection, 
the  frequent  involvement  of  the  testes  and  pancreas  pointing  in 
that  direction.  The  parotid  gland  is  infected  from  the  mouth, 
and  the  parotitis  is  frequently  accompanied  by  slight  stomatitis. 
The  affection  runs  its  well-known  course,  with  symmetric  swelling 
of  both  parotids,  hyperemia  of  the  skin,  light  fever,  moderate 
interference  with  the  general  condition,  painfulness  of  the  glands, 
and  occasionally  simultaneous  swelling  of  the  neighboring  glands. 
As  a  rule  it  subsides  within  a  week.  It  may,  however,  be  followed 
by  otitis,  a  possibility  which  should  be  given  due  consideration. 

Treatment. — An  affected  child  is  best  isolated.  If  there  is  fever, 
the  patient  is  put  to  bed.  To  relieve  the  painful  tension  over  the 
glands,  warm  oil  or  petrolatum  is  applied  to  the  swollen  parts  and 
covered  with  cotton,  or  an  application  of  aluminum  acetate  solu- 


330  DISEASES  OF  THE  MOUTH 

tion  is  made.  Frequent  rinsing  of  the  mouth  and  gargling  with 
a  2-per-cent.  solution  of  hydrogen  peroxid  is  advisable  to  pre- 
vent further  infection.  Should  the  swelling  not  readily  subside, 
unguentum  citrinum  may  be  rubbed  in.  In  case  of  ulceration,  an 
incision  will  be  necessary.  The  diet  should  be  fluid  or  pappy. 
Care  should  be  taken  to  maintain  regularity  of  the  bowels.  Com- 
plicating orchitis  is  treated  by  elevation  of  the  testicles  and  cold 
compresses. 

Chronic  Enlargement  of  the  Salivary  and  Lacrimal  Glands 
(Mikulicz's  Disease). — -This  rare  affection  is  characterized  by 
symmetric  and  simultaneous  involvement  of  the  lacrimal  and 
large  salivary  glands.  The  sublingual,  lingual  and  palatal  glands 
may  or  may  not  be  simultaneously  involved.  The  characteristic 
symptoms  consist  of  swelling  of  the  glands  referred  to,  which 
imports  a  striking,  characteristic  appearance  to  the  face.  The 
etiology  is  by  no  means  clear.  There  are  simple  cases  in  which 
only  the  glands  mentioned  are  affected,  and  others  in  which  the 
lymph  glands  and  the  spleen  also  are  swollen,  and  others  again 
presenting  leukemic  and  pseudoleukemic  blood  changes.  True 
hypertrophy  of  the  glands  seems  also  to  occur. 

Treatment. — Therapeutically,  Roentgen-ray  treatment  has  been 
successful. 

Ptyalism. — Excessive  secretion  of  saliva  occurs  as  a  concomitant 
manifestation  of  inflammatory  affections  of  the  oral  mucous  mem- 
brane, in  mercurial  poisoning,  and  as  a  nervous  affection.  The 
treatment  consists  in  removal  of  the  cause  and  restriction  of  the 
secretion  by  belladonna  preparations. 

Aptyalism. — This  condition  occurs  in  nervous  affections,  rarely  in 
inflammatory  ones.  It  is  associated  with  an  unpleasant  sensation  of 
dryness  in  the  mouth.  Pilocarpin,  0.005  to  0.01  Gm.  (TV  to  J  grain), 
subcutaneously  or  by  mouth,  may  be  tried,  to  incite  secretion  of 
saliva.  Painting  of  the  oral  mucosa  with  glycerin  may  relieve  to 
some  extent  the  sensation  of  dryness. 

PHLEGMONS  OF  THE  BUCCAL  FUNDUS. 

Ludwig's  Angina. — This  purulent  affection  occurs  in  the  loose 
vascular  and  lymphatic  connective  tissue  of  the  buccal  fundus  in 
which  the  salivary  glands  are  embedded.  This  tissue  becomes 
infected  through  disease  of  the  buccal  fundus,  after  operations 
and  injuries,  or  through  carious  teeth.  The  pathologic  picture 
usually  develops  very  rapidly,  a  hard  distention  of  the  region 
between  the  inferior  maxilla  and  the  hyoid  bone  occurring  inside 
of  a  few  hours.  This  rapidly  increases  and  is  accompanied  by 
considerable  edematous  swelling  of  the  skin  of  the  throat  and  chin. 
The  inflammatory  swelling  in  the  interior  of  the  mouth  extends 
to  the  deeper  connective  tissue  of  the  neck,  the  entrance  of  the 


AFFECTIONS  OF  THE  ALVEOLAR  PROCESSES  331 

glottis,  and  sometimes  to  the  mediastinum.  It  soon  produces 
difficulty  in  breathing.  The  head  is  carried  stiflly,  with  the  chin 
raised,  and  considerable  pallor  and  pronounced  cyanosis  rapidly 
make  their  appearance.  The  patient  can  hardly  open  his  mouth, 
and  inspection  of  the  cavity  is  difficult.  The  condition  must  there- 
fore be  ascertained  by  palpation.  The  tip  of  the  tongue  is, found 
raised,  often  closely  pressed  against  the  hard  palate  by  the  swollen 
tissues  underneath.  In  this  way  the  affection  soon  assumes  an 
extremely  dangerous  and  tormenting  aspect— dangerous  owing  to 
impeded  respiration  and  possible  general  septic  infection,  with 
chills,  fever,  icterus,  albuminuria,  and  endocarditis.  General  sepsis 
is  often  the  cause  of  death,  and  the  prognosis  is  therefore  very 
doubtful.  The  most  favorable  course  is  the  rapid  evacuation  of 
the  abscess,  the  pus  perforating  through  the  mucous  membrane 
of  the  buccal  fundus;  but  this  is  a  rather  rare  occurrence. 

Treatment. — The  possibility  of  rapid  extension  demands  ener- 
getic surgical  intervention.  Even  before  there  is  any  demonstrable 
pus,  free  incisions  must  be  made  in  every  case,  in  order  to  decrease 
the  tension  of  the  infiltrates  by  evacuation  of  blood  and  exudates. 
The  incision  is  best  made  close  to  the  submaxillary  margin,  to 
avoid  the  sublingual  artery,  the  lingual  nerve,  and  the  submaxillary 
duct.  Injuries  to  the  sublingual  gland  are  unimportant.  The 
incisions  should  be  tamponed  to  prevent  too  profuse  hemorrhage. 
The  galvanocautery  can  be  used  for  incising,  but  in  any  case  the 
incisions  must  be  made  at  great  depth,  because  the  pus  is  often 
located  as  deeply  as  beneath  the  sublingual  gland. 

AFFECTIONS  OF  THE  ALVEOLAR  PROCESSES. 

Parulis  (Periostitis  alveolaris  dentalis). — Gum-boil  is  often  associ- 
ated with  carious  teeth.  It  spreads  from  the  carious  points,  through 
the  pulp  to  the  apertures  of  the  dental  root  canals,  creeps  along  the 
alveolar  margin  and  continues  through  the  alveolar  wall  or  through 
the  osseous  canals  to  the  periosteum  of  the  alveolar  process.  In 
this  way  an  abscess  is  formed  underneath  the  maxillary  periosteum, 
usually  in  the  vicinity  of  the  apex  of  the  dental  root.  This  is 
accompanied  by  considerable  edematous  swelling  of  the  gums, 
finally  leading  to  much  swelling  of  the  adjacent  soft  parts  of  the 
cheek.  The  entire  process  may  run  a  very  acute  course,  in  which 
case  it  is  accompanied  by  severe  pains,  especially  when  the  tooth 
is  involved.  The  pains  are  somewhat  abated  as  the  abscess  is  being 
formed.  This  acute  and  very  painful  form  is  often  found  when 
the  pulp  is  not  freely  exposed,  and  so  the  inflammatory  products 
are  arrested  in  the  pulp  cavity.  If,  on  the  other  hand,  the  latter  is 
wide  open,  allowing  pus  and  inflammatory  products  to  escape,  the 
course  may  be  less  acute,  with  pain  from  mastication  or  other 
pressure  only.     Patients  have  a  sensation  of  the  teeth  being  too  long, 


332  DISEASES  OF  THE  MOUTH 

an  indication  that  they  are  not  firmly  held  in  the  alveoli.  Small  or 
large  pus  pouches  or  granulations  are  often  formed  at  the  apex  of 
the  roots.  By  this  means  a  chronic  periodontitis  may  be  changed  to 
alveolar  periostitis,  or  parulis.  In  the  acute  form  of  parulis  the 
general  condition  is  often  considerably  impaired  by  fever  and  head- 
ache. oThe  abscess  being  formed,  the  pus  soon  burrows  toward  the 
gums,  usually  toward  the  malar  side  of  the  alveolar  process,  and  at 
the  upper  lateral  incisors  toward  the  palate  or  buccal  fundus.  Under 
certain  circumstances  this  may  lead  to  palatal  abscesses,  which  are 
always  located  laterally.  At  times  the  perforation  does  not  take 
place  immediately,  but  assumes  the  shape  of  a  fistula,  the  so-called 
dental  fistula,  which  may  persist  for  a  long  time.  (Plate  XXIII.) 
The  pus  rarely  perforates  through  the  outer  skin;  when  it  does,  the 
point  of  exit  is  most  frequently  at  the  posterior  molar  teeth  of  the 
inferior  maxilla.  Perforation  toward  the  buccal  fundus  may  cause 
genuine  Ludwig's  angina,  rendering  the  diagnosis  difficult  (see 
page  330). 

Treatment. — Abscesses  are  incised,  preferably  parallel  to  the 
alveolar  margin.  A  useful  measure  is  to  keep  the  wound  open 
by  an  iodoform  tampon.  Above  all,  the  affected  tooth  is  removed 
or  adequately  treated,  in  order  to  prevent  a  recurrence.  It  is 
then  left  for  the  dentist  to  continue  the  correction  of  the  teeth. 
Wisdom  teeth  are  best  extracted,  because  they  do  not  readily 
lend  themselves  to  other  treatment  owing  to  their  hidden  position. 
Alveolectomy  may  be  done  in  selected  cases. 

Pyorrhea  Alveolaris. — The  accumulation  of  tartar  about  the 
neck  of  the  tooth  favors  the  development  of  pyorrhea  alveolaris,  or 
Rigg's  disease.  The  adjacent  gums  become  swollen,  with  a  red 
or  blue-red  edematous  appearance.  As  the  gum  margins  detach 
themselves,  pouches  and  crypts  are  formed,  containing  soft,  easily 
bleeding  granulation  tissue  and  slimy  detritus,  with  large  quantities 
of  endamebse,  spirochete,  and  bacteria.  These  masses  can  be 
expressed  by  pressure  upon  the  gum.  At  times  pus  also  is  evacu- 
ated. It  is  possible  with  a  thin  sound  to  uncover  the  neck  of  the 
tooth  for  a  considerable  distance.  The  affected  gums  bleed  easily. 
The  affection  is  at  first  almost  painless,  and  no  attention  is  paid  to 
it  for  a  long  time.  Gradually  the  tooth  becomes  loose,  causing  pain 
in  biting  and  masticating.  The  incisors  and  the  upper  anterior 
molars  are  attacked  first.  As  a  general  rule  the  teeth  of  the  upper 
maxilla  are  affected  sooner  than  those  of  the  lower.  In  most  cases 
single  groups  of  teeth  are  attacked  at  one  time,  rarely  all  the 
teeth  at  once.  The  diagnosis  in  doubtful  cases  is  easily  confirmed 
by  Roentgen-ray  examination. 

Treatment. — The  first  step  is  removal  of  the  accumulations  of 
tartar  by  the  dentist.  Pockets  of  any  appreciable  depth  are  freely 
incised  with  the  knife  or  galvanocautery,  each  tooth  being  treated 
separately.    The  pockets  are  then  rubbed  with  iodoform  mass  (page 


AFFECTIONS  OF  THE  LIPS  AND  CHEEKS  333 

298)  by  means  of  a  cotton-covered  sound.  Deeper  pockets  may  be 
tamponed  with  a  piece  of  iodoform  gauze.  This  simple  treatment 
will  often  effect  a  cure  in  a  few  weeks  in  light  cases,  the  incisions 
being  frequently  repeated  should  the  cut  edges  agglutinate.  If 
the  swelling  of  the  gums  persists,  it  is  advisable  to  cauterize  the 
margins  with  the  galvanocautery  or  the  silver  nitrate  stick.  As 
pyorrhea  is  often  found  in  tabes  and  diabetes  mellitus,  attention 
must  be  directed  to  these  diseases  as  well  as  to  other  constitutional 
ailments.  Emetin  given  by  subcutaneous  injection  or  orally 
affects  only  such  endamebre  as  are  within  the  reach  of  the  blood; 
those  on  the  surface  of  the  mucous  membrane  seem  not  to  be 
destroyed.  The  mucosa  itself  possesses  the  ability  to  prevent 
their  migration  through  it.  When  emetin  is  used  in  the  treatment 
of  pyorrhea,  two  drops  of  fluidextract  ipecac  in  a  tumbler  of  water, 
used  as  a  mouth-wash,  will  hasten  the  cure. 

Mercuric  succinimide  injected  intramuscularly  in  doses  of  0.06 
Gm.  (1  grain)  at  weekly  intervals,  until  six  injections  are  given, 
yields  gratifying  results  in  many  cases  of  pyorrhea  alveolaris.  The 
mercury  salt  is  dissolved  in  1  Cc.  (15  minims)  of  hot  sterile  distilled 
water  and  injected  in  the  manner  described  on  page  581. 

Attempts  have  been  made  to  treat  alveolar  pyorrhea  with  bac- 
terial vaccine.  Several  different  organisms  are  usually  present,  and 
an  autogenous  vaccine  should  be  made  up  for  each  case.  These 
vaccines  are  often  of  great  value.  A  stock  vaccine  containing 
cultures  of  the  organisms  usually  present  in  pyorrhea  cases  is  also 
to  be  had,  and  good  results  are  reported  from  its  use. 

The  teeth  should  in  no  case  be  extracted  so  long  as  they  are  firmly 
embedded;  even  loose  teeth  become  firm  again  under  appropriate 
treatment. 

In  endainebic  pyorrhea,  constitutional  conditions  secondary  to 
this  infection  often  occur,  the  most  frequent  being  arthritis  of  the 
so-called  deformans  type.  The  combined  local  and  systemic  treat- 
ment with  emetin  brings  about  recovery  in  a  large  percentage  of 
cases  (see  page  723) . 

Gingivitis  (Inflammation  of  the  gum). — Mechanical  factors,  such 
as  the  ingestion  of  too  hot  foods,  improper  ventilation,  mouth 
breathing,  and  gum  chewing,  enter  into  the  etiology  of  this  condition, 
as  well  as  bacteria. 

AFFECTIONS  OF  THE  LIPS  AND  CHEEKS. 

Congenital  Fistulse  of  the  Lower  Lip. — Fistulse  are  met  with 
not  only  in  cases  of  hare-lip,  but  in  otherwise  normal  lips.  Some- 
times they  constitute  a  family  affection.  They  are  usually  bilat- 
eral and  are  symmetrically  located  about  one  centimeter  from  the 
median  line,  forming  fine  ducts  up  to  one  centimeter  deep  which 
run   posteriorly   and   inferiorly   toward   the   mucous   membrane. 


334  DISEASES  OF  THE  MOUTH 

They  originate  in  a  semilunar  excavation  in  the  red  of  the  lips, 
which  is  often  present  in  subjects  free  from  fistula.  Mucous 
secretion  is  evacuated  through  the  external  orifice,  and  this  is 
the  only  inconvenience  occasioned  by  the  fistula,  which  is  probably 
due  to  incomplete  closure  of  embryonic  furrows. 

Acute  Cheilitis. — Acute  inflammation  of  the  lips  often  follows  in 
the  wake  of  injuries  or  other  affections  of  the  lips  (herpes  labialis, 
eczema,  etc.).  The  lips  may  become  considerably  swollen,  forming 
probosciform  eminences.  Acute  cheilitis  will,  of  course,  also  occur 
when  a  furuncle  or  carbuncle  appears  at  the  lips.  This  often  leads 
to  enormous  edematous  swelling  of  the  lips,  accompanied  by  great 
pain.  Labial  furuncles  and  carbuncles  are  often  the  cause  of 
general  infections.  The  possibility  of  an  anthrax  pustule  should 
always  be  thought  of  when  a  labial  furuncle  threatens  to  assume  a 
malignant  course.  The  anamnesis  and  bacteriological  examination 
will  then  establish  the  diagnosis.  An  abscess  of  the  lips  occasionally 
develops  from  infected  glands  of  the  mucous  membrane.  It  is 
located  rather  deeply  in  the  tissue  underneath  the  mucosa  and 
may  lead  to  great  pain  and  swelling. 

Treatment. — The  treatment  depends  upon  the  underlying  disease. 
Abscesses  must  be  incised.  Anthrax  pustules  are  to  be  excised 
only  in  the  very  beginning;  after  the  process  has  extended  further, 
a  waiting  attitude  is  indicated,  the  more  so  as  the  spontaneous 
cure  of  anthrax  pustules  is  no  great  rarity. 

Chronic  Cheilitis.  —  Cheilitis  Glandularis.  —  This  affection  is 
always  associated  with  swelling  of  the  lower  lip,  without  causing 
any  particular  complaint  until  the  lip  finally  becomes  much  swollen, 
firm  and  immovable.  It  originates  in  the  mucous  glands,  which 
may  become  enlarged  to  the  size  of  a  pea.  The  excretory  ducts 
are  dilated  and  secrete  viscid  mucus  or  purulent  fluid.  Ulceration 
of  the  swollen  glands  follows,  a  small  abscess  forming  which  per- 
forates toward  the  oral  cavity.  Mucus  and  pus  continue  to  be 
evacuated  at  the  place  of  perforation  for  a  long  time. 

For  internal  treatment,  potassium  iodid  is  recommended.  The 
abscesses  themselves  are  incised  or  cauterized,  after  which  they 
are  painted  with  tincture  of  iodin. 

Cheilitis  exfoliativa  is  located  at  the  lower  lip.  The  mucous 
membrane  is  intensely  red,  completely  loses  its  epithelium  in  spots, 
and  becomes  loose.  The  affected  lip  is  exceedingly  painful,  causing 
the  patient  to  continually  press  it  outward  to  avoid  contact  with 
the  teeth.  In  this  way  the  ailment  becomes  very  tormenting. 
It  may  last  several  weeks  or  months,  but  appears  to  be  subject 
to  spontaneous  cure. 

There  is  no  special  treatment  for  this  affection.  Covering  the 
affected  labial  mucosa  with  mild  salves  or  boric  acid  ointment, 
spread  on  a  small  piece  of  linen,  gives  material  relief. 


BENIGN  TUMORS  OF  THE  MOV TH  335 


AFFECTIONS  OF  THE  MALAR  MUCOSA. 

The  malar  as  well  us  the  labial  mucosa  is  subject  to  glandular 
disorder.  The  lymph  glands  located  in  the  cheek  are  not  infre- 
quently affected,  and  may  swell  in  tonsillitis  and  coryza. 


BENIGN  TUMORS  OF  THE  MOUTH. 

The  mouth  may  harbor  all  known  forms  of  tumors,  some  of  them 
with  especial  frequency. 

Fibroma. — When  pure  fibroma  occurs  in  the  mouth,  which  it 
rarely  does,  it  is  most  frequently  found  upon  the  surface  of  the 
tongue  and  has  a  more  or  less  pediculated  form;  occasionally 
fibromata  are  found  deeply  embedded  in  the  lingual  substance.  The 
tumors  are  usually  very  hard.  Neurofibromata  likewise  occur  in  the 
tongue.  The  superficial  tumors  may,  as  a  matter  of  course,  exhibit 
the  most  varied  forms  and  sizes.  The  important  point  is  that  they 
are  always  sharply  demarcated  from  the  surrounding  tissue.  Their 
slow  growth  is  characteristic.  As  a  rule  they  cause  but  slight  dis- 
comfort until  they  attain  considerable  size.  The  surface  of  the  soft 
tumors  may  under  certain  circumstances  become  ulcerative.  Lin- 
gual fibroma  is  met  with  congenitally  in  infants  and  at  any  later 
age.  The  diagnosis  is  not  easy  when  the  tumors  are  soft,  especially 
when  they  ulcerate  and  bleed.  In  that  case  syphilis  should  be 
taken  into  consideration.  Carcinoma  is  in  most  cases  distinguished 
by  its  characteristic  appearance.  The  differentiation  from  sarcoma 
is  a  matter  of  great  difficulty  in  certain  cases. 

Treatment. — When,  in  doubtful  diagnosis,  potassium  iodid  and 
mercury  have  failed,  the  alternative  is  operation.  Fibromata  can 
always  be  very  easily  enucleated  under  local  anesthesia.  Should 
enucleation  be  difficult,  the  best  plan  is  to  make  an  exploratory 
excision  for  microscopic  examination,  further  surgical  steps  to 
depend  upon  the  findings.  The  application  of  the  Roentgen  ray 
gives  good  results. 

As  stated,  fibromata  are  very  rare  in  other  parts  of  the  mouth. 
They  have  been  described  as  occurring  in  the  hard  palate,  at  the 
uvula,  palatal  arches,  interior  surface  of  the  upper  lip,  and  the  malar 
mucosa. 

Lipoma. — The  tongue  is  most  frequently  the  seat  of  oral  lipoma; 
fibrolipoma  usually  occurs  singly.  In  most  case  lipomata  are 
located  immediately  under  the  surface,  rarely  intramuscularly. 
They  are  usually  smooth  to  the  touch,  of  roundish  shape,  and  may 
attain  to  the  size  of  a  hen's  egg.  In  making  the  diagnosis,  gumma 
of  the  tongue  has  to  be  considered.  Lipoma  has  been  observed 
at  the  fundus  of  the  mouth,  where  it  can  give  rise  to  symptoms 
by  pressing  the  tip  of  the  tongue  upward;  in  that  case  the  diagnosis 


336  DISEASES  OF  THE  MOUTH 

may  be  more  difficult.    There  are  also  lipomata  of  the  cheek,- but 
the  lips,  gums  and  palate  are  very  rarely  attacked. 

Treatment. — Lipomata  can  always  be  easily  removed  by  surgical 
operation. 

Myxoma. — Myxomata  in  the  mouth  are  extremely  rare.  A  pure 
myxoma  has  been  observed  on  the  malar  mucosa.  These  growths 
occur  occasionally  at  the  point  of  fusion  between  the  hard  and  the 
soft  palate. 

Myoma. — Myoniata  are  very  rare. 

Chondroma,  Osteoma. — These  growths  occur  at  the  soft  parts 
of  the  mouth,  but  very  seldom.  Lipo-  and  fibro-chondromata  have 
also  been  observed. 

Hemangioma. — Telangiectasia  (angioma  simplex)  consists  of  a 
clump  of  minute  bloodvessels  and  occurs  at  points  where  embryonic 
fissures  have  undergone  fusion.  It  appears  as  a  flat,  slightly  gib- 
bous, sharply  but  irregularly  demarcated  red  or  blue-red  tumor. 
The  majority  of  these  little  tumors  are  congenital.  Their  favorite 
site  is  the  lips,  especially  at  the  external  surface  and  the  red  part. 
When  these  growths  become  larger  they  develop  into  cavernous 
angiomata. 

Cavernous  Angiomata. — These  are  tumors  of  various  sizes  con- 
sisting of  numerous  bloodvessels  which  form  dilated  thin-walled 
cavities  of  spongy  tissue.  The  simultaneous  appearance  of  telan- 
giectasia and  angioma  cavernosum  is  not  infrequent.  Angio- 
lipoma  and  angiosarcoma  are  also  to  be  considered.  The  cavern- 
ous angioma  has  a  bluish  color,  a  gibbous  surface,  and  a  flabby 
feel.  It  can  easily  be  evacuated  by  pressure.  It  occurs  at  all 
points  in  the  mouth,  but  most  frequently  in  the  tongue.  It  is  often 
multiple,  notably  when  located  at  the  anterior  part  of  the  tongue. 
These  growths  may  attain  to  considerable  size  and  occasionally 
spread  to  the  buccal  fundus.  They  have  also  been  observed  at 
the  cheeks  and  lips.  They  are  really  benign  tumors  without  metas- 
tases, but  have  often  a  great  tendency  to  extend  to  adjacent  tissues. 
They  may  also  give  rise  to  serious  hemorrhages.  Furthermore, 
they  are  associated  with  light  inflammatory  manifestations  which 
involve  the  danger  of  general  septic  infection. 

Treatment. — In  consideration  of  these  dangers  the  removal  of  the 
tumor  is  very  desirable.    This  can  only  be  done  by  surgery. 

Racemose  Aneurysm. — Racemose  aneurysm  occurs  almost  ex- 
clusively in  the  head  and  represents  the  well-known  dense  plexus  of 
largely  dilated,  tortuous,  communicating  arteries.  The  tumors  of 
the  head  and  face  may  occasionally  spread  to  the  oral  mucosa  and 
form  large  tumors.  This  can  most  readily  happen  with  aneurysm 
of  the  internal  maxillary  artery,  where  the  newly  formed  vessels 
extend  to  the  labial  mucosa,  gums  and  palatal  arches,  giving  rise  to 
hemorrhages  which  can  only  with  difficulty  be  arrested. 

Treatment  is  exceedingly  difficult  and  at  times  almost  impossible. 


BENIGN  TUMORS  OF  THE  MOUTH  337 

Lymphangioma. — Lymphangiomata  often  occur  in  the  mouth, 
particularly  at  the  tongue  in  the  shape  of  verrucous,  nodiform, 
diffuse  and  aplastic  growths.  They  are  probably  neoplasms  of 
lymph  vessels  and  lymphoid  tissue  of  congenital  origin.  They 
are  usually  situated  at  the  location  of  closed  embryonic  fissures. 
They  can  often  be  observed  at  the  earliest  age,  and  remain  small 
for  a  long  time.  As  a  rule  they  increase  in  size  intermittently 
in  connection  with  the  occurrence  of  inflammatory  processes  of 
the  tumor  tissue.  Inflammations  of  this  kind  are  easily  caused  by 
topical  injuries.  Coincidently  there  may  be  considerable  swelling 
of  the  tongue  or  pronounced  glossitis.  These  inflammatory  pro- 
cesses  always  involve  the  danger  of  infection  of  the  cervical  con- 
nective tissue  and  edema  of  the  glottis. 

Nodiform  and  verrucous  lymph  glands  occur  at  the  margins  or 
dorsal  part  of  the  tongue  in  the  shape  of  coarse  tumors  of  varying 
size,  the  uneven  surface  of  which  resembles  lingual  papilke.  The 
small  eminences  on  the  tumor,  however,  are  not  true  papillae,  but 
rather  vesicles  containing  fluid,  which  can  often  be  recognized  as 
such  macroscopically.  A  large  number  of  small  foci  can  thus  be 
formed  on  the  tongue  in  an  irregular,  diffuse  way,  or  even  large 
coherent  tumors.  Just  at  the  time  when  a  glossitis  is  newly  devel- 
oped, an  entire  half  or  the  whole  of  the  tongue  is  enlarged,  hyper- 
emic  and  painful,  and  the  real  cause  of  the  glossitis  may  be  entirely 
overlooked. 

Diffuse  Lymphoma. — It  has  already  been  mentioned  that  macro- 
glossia  may  be  caused  by  lymphoma  formation.  There  are  small, 
fluid-containing  vesicles  under  the  transparent  surface  of  the  lin- 
gual mucous  membrane,  which  are  diffusely  disseminated  over  the 
larger  part  of  the  tongue,  not  only  on  the  surface,  but  also  in  the 
lingual  substance.  As  a  result  the  tongue  may  become  so  large 
that  part  of  it  will  protrude  from  the  mouth  and  be  thereby  exposed 
to  a  variety  of  injuries,  infections,  and  desiccation.  The  enlarged 
tongue  may  cause  displacement  of  the  teeth,  and  the  entire  sub- 
maxillary bone  may  become  deformed. 

Cystic  lymphoma  is  exceedingly  rare,  and  is  usually  situated  at  the 
anterior  part  of  the  tongue;  it  may  attain  to  the  size  of  a  lemon. 
It  also  occurs  at  the  lips,  especially  the  upper  one,  the  cheeks, 
and  the  buccal  fundus.  Inflammatory  manifestations  may  also, 
though  rarely,  be  associated  with  this  growth.  The  formation  of 
vesicles  is  a  characteristic  diagnostic  point. 

Treatment. — Small  flat  lymphomata  of  the  first  named  variety 
may  be  left  undisturbed,  unless  they  cause  discomfort.  The  larger 
tumors  will  have  to  be  removed  surgically.  The  operations  should 
be  carried  out  at  a  time  when  there  are  no  inflammatory  manifesta- 
tions.    Good  results  have  been  attained  with  the  cautery. 

Dermoid  Cysts. — Dermoid  cysts  do  not  often  occur  in  the  mouth. 
When  they  do  they  are  found  almost  exclusively  at  the  fundus, 
22 


338  DISEASES  OF  THE  MOUTH 

either  exactly  in  the  center  or  close  to  the  median  line.  The  medial 
cysts  are  distinguished  from  the  submental  and  the  sublingual. 
They  originate  in  all  cases  from  an  epidermal  cell  caught  in  the 
closure  of  embryonic  fissures.  They  are  mostly  found  densely 
arranged  at  and  behind  the  medial  part  of  the  inferior  maxilla  or 
the  hyoid  bone,  a  fact  which  likewise  points  to  embryonic  origin. 
The  sublingual  dermoids  belong  entirely  to  the  buccal  variety; 
they  bulge  out  considerably  in  the  region  of  the  frenum  linguse, 
raise  the  tip  and  posterior  part  of  the  tongue,  and,  as  they  grow, 
may  cause  in  this  way  considerable  trouble  in  swallowing  and 
.speaking.  The  submental  dermoids,  when  greatly  developed,  may 
cause  a  kind  of  double-chin,  together  with  serious  difficulty  in 
swallowing  and  breathing.  Since  the  cysts  grow  very  slowly, 
patients  usually  get  accustomed  to  them  so  that  no  notice  is  taken 
of  them  until  a  relatively  late  stage.  Inflammatory  processes  and 
trauma  may  cause  a  rapid  increase  in  their  growth.  The  buccal 
aspect  of  a  sublingual  dermoid  is  spherical  or  oval,  with  a  smooth 
and  movable  investing  membrane.  The  walls  are  usually  very  thick. 
Pressure  upon  the  cysts  may  leave  an  impression.  Bimanual 
palpation  will  serve  to  determine  the  exact  position.  Movement 
of  the  tumor  in  swallowing  indicates  its  firm  adhesion  to  the 
hyoid  bone. 

Treatment. — Enucleation  is  therapeutically  the  most  desirable 
procedure;  it  is  easy  in  all  cysts  which  have  not  passed  through 
any  inflammatory  process.  In  the  new-born  who  cannot  nurse 
well,  owing  to  cysts,  puncture  may  perhaps  suffice,  enucleation 
being  postponed  to  a  later  period.  Excision  of  only  part  of  the 
cysts,  followed  by  irritation,  or  puncture,  with  subsequent  injection 
of  tincture  of  iodin,  is  to  be  deprecated,  since  these  procedures  may 
easily  lead  to  inflammatory  processes  in  the  neighborhood  of  the 
cysts. 

Cysts  Originating  from  Glands. — Cysts  in  the  mouth  are  often 
found,  the  walls  of  which  are  invested  with  glandular  epithelium, 
and  which  contain  fluid  or  mucous  masses. 

Superficial  cysts  of  the  mucous  membrane  are  probably  the  result 
of  the  excretory  ducts  of  the  glands  having  been  occluded  by  inflam- 
matory processes.  The  cysts  are  most  frequently  found  where 
there  is  the  greatest  accumulation  of  glands — the  inner  surface  of  the 
lips,  the  malar  mucosa,  the  dorsal  surface  of  the  tongue,  especially 
in  the  region  of  the  papillae  vallatse,  and  the  inferior  surface  of 
the  tongue.  They  have  only  rarely  been  observed  at  the  uvula. 
The  size  of  the  cysts  varies  from  a  millet  seed  to  a  pea.  Their 
walls  are  usually  very  thin  and  transparent.  The  subjective 
symptoms  are  very  slight  in  most  cases,  and  often  do  not  arise 
until  the  appearance  of  inflammatory  manifestations. 

Treatment. — Enucleation  of  the  cysts  under  local  anesthesia. 


BENIGN  TUMORS  OF  THE  MOUTH  339 

Ranula. — Cysts  of  the  buccal  fundus  are  due  to  enclosure  of 
epithelial  elements  in  the  palatal  fissures,  or  to  occlusion  of  excre- 
tory ducts  of  various  glands,  such  as. the  sublingual,  the  sub- 
maxillary, the  glandula  incisiva  at  the  neck  of  the  central  and 
lateral  incisors,  Nuhn's  glands  in  the  tongue,  and  the  numerous 
little  mucous  glands  of  the  buccal  mucosa.  Ordinarily  it  is  diffi- 
cult to  say  from  which  gland  a  ranula  emanates.  When  located 
precisely  in  the  center,  it  may  be  ascribed  to  epithelial  enclosures. 
In  most  cases  it  lies  close  to  the  median  line,  immediately  below  the 
mucous  membrane.  It  appears  at  the  buccal  fundus  between  tongue 
and  inferior  maxilla  as  a  bluish-red  or  bluish-white,  roundish, 
transparent  tiunor,  displacing  the  organs  of  the  buccal  fundus  to 
a  smaller  or  greater  extent  according  to  its  size,  and  causing  dis- 
comfort of  varying  degrees  in  swallowing  and  speaking.  The  diag- 
nosis can  readily  be  made  from  the  presence  of  fluctuation  and  by 
bimanual  examination.  As  a  rule  the  tumors  grow  very  slowly. 
Infection  of  the  ranula  may  lead  to  very  unpleasant  inflammatory 
processes  in  the  buccal  fundus. 

Treatment.- — The  best  treatment  in  simple  cases  is  the  use  of  a 
hair  rope,  i.  e.,  conducting  a  silk  thread  through  the  cyst  and  tying 
the  ends  together.  This  will  serve  to  gradually  evacuate  the 
cyst.  The  thread  is  allowed  to  remain  in  position  for  six  to  eight 
days,  by  which  time  it  will  have  automatically  cut  through  the 
ligated  tissue.  Meanwhile  the  cystic  walls  may  have  completely 
grown  together  and  atrophy  commenced,  preventing  refilling  of 
the  cyst.  Excision  of  a  piece  of  the  cystic  wall  may  have  the  same 
effect.  Mere  puncture  is  almost  invariably  followed  by  recurrence. 
Should  the  hair  rope  method  fail,  the  cyst  should  be  completely 
extirpated. 

Cysts  at  the  Root  of  the  Tongue  are  but  rarely  observed.  They 
may  attain  to  the  size  of  a  hazelnut  or  a  small  apple.  These  cysts 
originate  from  the  superficial  mucous  glands  of  the  root  of  the 
tongue  and  from  remnants  of  the  thyroglossal  duct.  The  latter  are 
embedded  either  superficially  or  deeply  in  the  lingual  substance; 
their  epithelium  is  partly  of  the  ciliary  variety.  When  the  c}rsts 
disturb  speech  or  respiration,  or  produce  the  sensation  of  the 
presence  of  a  foreign  body,  operative  interference  is  called  for. 
A  hair  rope  may  be  applied  as  in  ranula,  or  a  piece  of  the  wall  may 
be  extirpated.  This  proceeding,  however,  is  successful  only  in 
unilocular  cysts;  multilocular  ones  require  as  complete  an  extir- 
pation as  possible.    Hemorrhage  may  be  considerable. 

Struma  of  the  Lingual  Base. — The  strumas  are  flat  or  semiglobular 
tumors,  smooth  or  gibbous,  of  soft  consistency,  and  covered  with 
normal  mucous  membrane.  They  are  usually  situated  in  the  median 
plane  between  the  hyoid  bone,  epiglottis  and  cecal  foramen.  They 
result  from  remnants  of  the  thyroglossal  duct — which,  of  course, 
is  the  residue  of  the  epithelial  depression  from  which  the  thyroid 


340  DISEASES  OF  THE  MOUTH 

gland  is  formed.  Lingual  struma?,  therefore,  are  accessory  thyroid 
glands.  They  are  very  rare  in  males,  and  are  usually  discovered 
at  the  time  of  puberty.  As  to  diagnosis,  confusion  with  cysts  of 
the  lingual  base  should  be  guarded  against. 

Treatment. — Serious  symptoms  from  enlargement  of  the  strumse, 
inflammations,  and  hemorrhages,  may  demand  operative  interven- 
tion. Removal  of  superficial  prominent  glands  is  usually  easy, 
under  local  anesthesia,  with  the  galvanocautery  loop.  Nodules 
located  deeply  in  the  lingual  musculature  toward  the  hyoid  bone 
may  have  to  be  removed  from  without.  Attempts  have  also  been 
made  to  reduce  the  tumor  by  the  administration  of  thyroid  or 
thymus  substance.  Previous  to  operation,  it  should  be  ascertained 
whether  the  thyroid  is  normal,  because  in  some  cases  myxedema 
has  been  observed  to  follow  operation. 

Adenoma. — Adenomata  of  the  mouth  are  very  rare.  They  have 
been  observed  at  the  sublingual  gland,  the  uvula,  and  the  mucous 
glands  of  the  lips. 

Papilloma. — Papillomata  are  often  found  in  the  mouth.  They 
preponderate  in  the  male  sex,  possibly  in  consequence  of  excessive 
use*  of  alcohol  and  tobacco,  and  may  perhaps  be  regarded  as  a 
product  of  chronic  irritation.  They  are  usually  situated  at  the 
uvula  and  the  palatal  arches,  seldom  at  the  tongue,  where  they 
prefer  the  lingual  base.  Most  papillomata  remain  small,  from  the 
size  of  a  pinhead  to  that  of  a  pea,  rarely  exceeding  the  size  of  a  hazel- 
nut. Owing  to  their  smallness,  they  cause  little  complaint.  The 
diagnosis  can  be  easily  made  from  the  fine  and  coarse  eminences 
covering  the  surface. 

Treatment. — Papillomata  are  to  be  removed  with  knife  or  scissors. 

Endothelioma. — Endotheliomata  originate  from  either  the  endo- 
thelium or  the  perithelium.  The  newly  formed  cells  are  found 
in  nests  and  cords  in  the  meshes  of  a  trabecular  stroma.  The 
histologic  diagnosis  is  by  no  means  easy  at  times,  especially  owing 
to  the  similarity  of  the  histologic  picture  to  carcinoma.  The  con- 
nective tissue  has  a  great  tendency  to  undergo  a  variety  of  changes, 
for  instance  into  bone,  cartilage,  fat,  mucous  and  hyaline  degenera- 
tions, with  the  consequence  that  often  there  are  genuine  mixed 
tumors.  Endotheliomata  occupy  the  border-line  between  benign 
and  malignant  tumors,  since  they  are  apt  to  run  a  thoroughly 
benign  course  for  many  years  and  then  suddenly  exhibit  a  malig- 
nant, sarcomatous  character. 

Their  place  of  predilection  is  in  the  most  glandular  strata  of 
the  mucous  membrane.  They  are  most  frequently  found  in  the 
hard  and  soft  palates,  where  the  glands  are  most  profuse.  Beside  j, 
endotheliomata  have  been  observed  at  the  buccal  fundus,  upper 
lip,  cheeks,  and  tongue.  Palatal  endotheliomata  are  always  situ- 
ated laterally,  forming  flat  or  globular,  smooth  or  slightly  gibbous 
eminences,  of  very  hard  or  tough  elastic  consistency.     They  are 


MALIGNANT  TUMORS  OF  THE  MOUTH  341 

covered  with  smooth,  movable  mucous  membrane.  Their  size 
varies  from  the  smallest  diameter  to  enormous  dimensions,  so 
that  the  mouth  may  be  completely  filled.    Their  growth  generally 

is  very  slow.  The  surface,  being  exposed  to  external  injury,  may 
ulcerate.  In  most  cases  the  tumor  is  distinctly  encapsulated,  but 
the  capsule  will  be  perforated  as  soon  as  a  tendency  to  malignant 
growth  develops.  The  clinical  diagnosis  often  presents  difficulties 
in  differentiation  from  other  tumors.  The  subjective  symptoms 
are  purely  mechanical,  as  in  swallowing,  speaking  and  masticating. 
Pains  accompany  ulceration,  and  when  the  tumor  is  located  in 
the  palate,  they  radiate  toward  the  ear. 

Treatment. — When  the  tumors  are  encapsulated,  which  is  usually 
the  case,  they  can  be  easily  enucleated  through  a  longitudinal 
incision.  Endotheliomata,  even  when  apparently  not  malignant, 
tend  to  recur  after  excision. 

MALIGNANT  TUMORS  OF  THE  MOUTH. 

Sarcoma. — The  majority  of  the  sarcomata  observed  in  the 
mouth  have  been  found  in  one  or  another  part  of  the  tongue.  The 
picture  varies  considerably,  the  tumors  differing  materially  as  to 
size,  shape  and  appearance.  They  ma}'  be  located  in  the  lingual 
parenchyma  or  pedunculated  upon  the  tongue.  Ulceration  is 
rare.  The  largest  lingual  sarcoma  so  far  observed  weighed  400 
grams  (13  ounces).  Microscopically  they  are  usually  small  round- 
celled  sarcomata,  but  spindle-celled  sarcomata  and  fibrosarcomata 
also  occur. 

Aside  from  the  mechanical  symptoms  caused  by  the  size  of  the 
tumor,  sarcoma  often  causes  pains  which  radiate  to  the  ear  of 
the  corresponding  side,  and  which  may  become  exceedingly  violent. 
In  most  cases  the  tumor  grows  relatively  slowly;  but  there  may  also 
be  sudden  advances.  Metastases  are  not  frequent;  when  they  do 
occur  it  is  usually  in  lymph  glands.  For  this  reason,  as  well  as  on 
account  of  the  easy  demarcation  of  the  sarcomata,  their  prognosis 
is  comparatively  favorable.  Local  recurrences  often  take  place 
after  operation,  but  when  these  have  been  attended  to  a  complete 
cure  is  sometimes  effected.  The  diagnosis  can  be  assisted  by  an 
exploratory  excision,  or  it  may  be  necessary  to  resort  to  experi- 
mental antisyphilitic  treatment.  For  this  purpose  large  doses  of 
potassium  iodid,  4  to  8  Gm.  (1  to  2  drams)  daily,  are  administered, 
which,  in  the  event  of  a  gmnmatous  infection,  would  have  a  favor- 
able effect  in  about  two  weeks.  If  the  sarcoma  is  extensively 
ulcerated,  it  is  almost  impossible  to  distinguish  it  from  carcinoma, 
but  so  far  as  therapy  is  concerned  this  is  immaterial. 

Sarcoma  has  been  found  in  the  palate.  A  few  cases  of  melano- 
sarcoma  in  the  hard  palate  have  also  been  described.  Myxosar- 
coma has  been  observed  at  the  malar  mucosa  in  verv  rare  cases. 


342  DISEASES  OF  THE  MOUTH 

Treatment. — As  soon  as  the  diagnosis  of  sarcoma  is  assured,  the 
tumor  should  be  removed.  In  doubtful  diagnosis  but  satisfactory 
demarcation  an  attempt  may  be  made  to  enucleate  the  tumor.  In 
inoperable  cases  Coley's  mixture  of  erysipelas  and  prodigiosus  toxins 
maybe  injected  hypodermically  in  very  small  and  gradually  increased 
doses;  or  arsenic,  Roentgen  ray  and  radium  treatment  may  be  tried, 
to  reduce  or  remove  the  growth. 

Carcinoma. — Carcinoma  of  the  mouth  is  of  very  frequent  occur- 
rence. It  is  a  surprising  fact  that  the  male  sex  is  preeminently 
affected.  Carcinoma  of  the  tongue  and  mouth  occurs  in  the  pro- 
portion of  nine  men  to  one  woman.  The  reason  for  this  dispropor- 
tion is  to  be  found  in  the  use  of  tobacco.  Smoking,  rough  teeth  and 
the  use  of  too  hot  drinks  are  important  etiologic  factors  in  mouth 
cancer.  It  has  already  been  mentioned  that  leukoplakia  predisposes 
to  carcinoma.  Statistical  figures  of  159  cases  of  lingual  carcinoma, 
compiled  by  von  Bergmann,  show  that  in  about  34  per  cent,  leuko- 
plakia may  be  assumed  to  have  been  the  cause.  Chronic  labial 
eczema  likewise  seems  to  furnish  suitable  soil  for  the  development 
of  carcinoma.  The  ultimate  causes  have  not  yet  been  discovered. 
Primary  carcinoma  almost  always  occurs  singly. 

Carcinoma  of  the  Lips  is  oftener  of  the  lower  than  of  the  upper  lip, 
the  proportion  being  about  17  to  1.  It  is  mostly  located  laterally, 
but  its  onset  almost  invariably  escapes  notice.  The  first  changes 
attracting  attention  are  usually  small,  flat  indurations  in  the  red 
of  the  lips,  in  the  vicinity  of  the  skin  border.  This  indurated  spot 
loses  its  epithelium,  voids  some  secretion,  and  bleeds  easily.  The 
small  tumor  gradually  grows  and  the  indurated  area  enlarges. 
A  genuine  tumor  develops,  in  the  fundus  of  which  there  are  often 
yellowish-red  nodules  the  size  of  a  pinhead  on  a  red  base — the 
carcinoma  nests.  Gradually  the  margins  become  prominent,  ram- 
part-like, and  ever  increasing  parts  of  the  lip  become  involved. 
This  causes  stiffness  and  immobility  of  the  lip — symptoms  which 
are  often  the  first  to  send  the  patient  to  his  physician.  The  tumor 
at  this  phase  may  undergo  sudden  advances,  especially  under 
inappropriate  treatment  with  irritating  ointments,  etc. 

Next  there  is  swelling  of  the  regional  lymph  glands,  first  of 
the  submental,  then  of  the  sublingual.  The  cervical  glands,  at 
a  greater  distance,  are  next  attacked.  The  symptoms  increase 
largely  if  the  tumor  spreads  to  the  gums  and  inferior  maxilla. 
The  lymph  glands  may  attain  to  the  size  of  large  tumors.  Sup- 
puration and  ichorization  are  constantly  increasing,  until  the 
patient  gradually  succumbs  to  the  disease.  The  possible  duration 
of  the  disease  has  been  calculated  to  be  up  to  three  and  one-half 
years. 

Treatment. — Radical  operative  removal  of  the  tumor  is  impera- 
tive, as  long  as  there  is  a  chance  of  success.    All  attempts  with 


MALIGNANT  TUMORS  OF  THE  MOUTH  343 

cautery  or  caustics  are  to  be  condemned.  The  excision  should 
extend  liberally  into  the  healthy  tissue.  In  very  early  operations 
permanent  cures  are  frequent,  and  some  statistics  report  up  to  90 
per  cent,  of  successes.  In  inoperable  cases,  caustic  pastes,  radium 
and  Roentgen-ray  treatment  may  be  tried,  and  the  symptoms 
should  meanwhile  be  relieved  by  the  free  use  of  narcotics. 

Carcinoma  of  the  Tongue. — Carcinoma  often  invades  the  tongue 
with  signs  of  pronounced  malignancy.  This  is  due  to  the  pro- 
pinquity of  the  buccal  fundus,  which  is  early  involved,  and  in  the 
loose  tissues  of  which,  abounding  in  lymph  currents,  the  neoplasm 
spreads  with  great  rapidity.  Superficial  carcinoma  of  the  tongue, 
which  distinctly  preponderates,  has  histologically  been  proved  to 
be  typical  carcinoma  of  the  pavement  epithelium,  and  is  distin- 
guished from  deep,  so-called  glandular  carcinoma  of  the  tongue. 
The  latter  emanates  from  the  deeper  lingual  layers  and  is  at  first 
located  below  the  mucosa,  without  ulcerating,  but  later  perforates 
the  mucosa  and  ulcerates.  Carcinoma  of  the  cylindric  epithelium 
of  the  tongue  is  very  rare. 

The  affection  begins  as  a  small  flat  ulcer  or  a  small  nodular 
infiltration  at  the  surface  of  the  tongue,  which  is  at  first  sharply 
demarcated  from  the  surroundings.  The  border  soon  becomes 
less  distinct,  and  the  tumor  penetrates  from  all  sides  into  the 
lingual  substance.  Ulceration  soon  sets  in,  with  a  rampart-like 
thickening  of  the  margins  of  the  tumor.  The  appearance  of  the 
latter  at  this  stage  is  particularly  characteristic,  greatly  facilitating 
the  diagnosis,  especially  in  the  presence  of  pain.  Hemorrhages 
from  mechanical  causes  occur  easily.  As  long  as  the  tumor  is 
confined  to  the  tongue  the  surrounding  lymph  glands  remain 
unaffected,  so  far  as  palpation  is  able  to  establish.  Should  the 
growth  extend  to  the  inferior  lingual  surface  and  the  buccal  fundus, 
the  tongue  will  become  immovable,  more  and  more  interfering 
with  mastication  and  deglutition.  Stagnant  food  remnants  cause 
repulsive  ichorization  which  almost  defies  irrigation.  Further 
development  and  metastases  now  proceed  in  the  lymph  glands, 
death  finally  ensuing  from  inanition.  The  average  duration  of  the 
disease  has  been  calculated  at  a  little  over  a  year.  Everything, 
of  course,  depends  upon  an  early  diagnosis  and  an  equally  early 
operation.  Both  early  detection  and  the  necessary  differential 
diagnosis  may  offer  considerable  difficulties.  Experimental  anti- 
syphilitic  treatment  should  be  carried  out  very  energetically  and 
very  rapidly.  A  laboratory  excision  is  likewise  very  useful.  Dif- 
ferentiation between  gumma  and  carcinoma  offers  the  greatest 
difficulties,  especially  since  both  processes  may  be  present,  and 
because  carcinoma  may  develop  upon  the  soil  of  a  gummatous 
ulcer.  Metastases  in  internal  organs  are  rare.  For  this  reason, 
lingual  carcinomata  still  belong  to  the  comparatively  benign  forms 


344  DISEASES  OF  THE  MOUTH 

which  offer  good  chances  of  a  cure  when  operation  is  performed 
early. 

Treatment. — The  object  of  the  treatment  is  the  operative  removal 
of  the  tumor.  Statistics  indicate  that  cures  of  more  than  three 
years'  duration  have  been  effected  in  about  30  per  cent,  of  the 
cases  treated  by  the  present-day  operative  technic.  This  result 
is,  of  course,  only  possible  when  the  involved  glands  can  be  simul- 
taneously extirpated.  The  operation  of  today  no  longer  encounters 
the  difficulties  of  former  times.  In  inoperable  cases,  narcotics  and 
local  anodyne  measures  are  administered  on  a  liberal  scale.  Ichori- 
zation  can  be  minimized  with  iodoform  gauze  and  irrigations. 
The  lingual  nerve  is  sometimes  dissected  for  the  purpose  of  alle- 
viating the  pain,  which  is  oftentimes  excruciating.  In  cases  of  this 
kind,  treatment  with  the  Roentgen  ray  and  radium  should  be  tried. 
The  radium  treatment  is  often  successful  in  incipient  cases.   . 

Carcinoma  of  the  Buccal  Fundus. — Primary  carcinoma  of  the  buccal 
fundus  is  very  rare.  Superficial  or  deep  carcinomata  in  this  loca- 
tion produce  functional  disorders  of  the  tongue  at  an  early  stage. 
The  treatment  is,  of  course,  surgical,  so  far  as  possible. 

Carcinoma  of  the  Malar  Mucosa/ — Carcinoma  of  the  malar  mucosa 
is  often  found  opposite  carious  teeth;  most  cases  are  superficial 
carcinoma  of  pavement  epithelium.  The  seat  of  predilection  is 
the  hindmost  part  of  the  cheek  pouches,  whence  the  neoplasm 
easily  extends  to  the  intermaxillary  fold,  resulting  in  spasm  in  a 
short  time.  This  may  render  the  diagnosis  very  difficult.  These 
carcinomata,  however,  do  not  run  as  malignant  a  course  as  those  of 
the  tongue,  and  are  often  locally  restricted  for  a  long  period. 

Treatment. — Extirpation  of  the  carcinoma,  and  plastic  covering 
of  the  destroyed  part  of  the  malar  mucosa.  Lateral  pharyngotomy, 
with  resection  of  the  submaxillary  branch,  may  become  necessary. 

Carcinoma  of  the  Palate. — Primary  carcinoma  of  the  palate  is 
very  rare.  Its  forms  are:  superficial,  of  pavement  epithelium; 
and  glandular,  from  the  palatal  glands.  The  superficial  form  is 
found  most  frequently  in  the  posterior  part  of  the  hard  palate, 
but  also  occasionally  in  the  soft  palate.  As  long  as  deep  carcinoma 
is  not  ulcerating,  it  presents  a  flat  tumor  with  a  smooth  hard  sur- 
face which  protrudes  into  the  oral  cavity.  It  may  easily  perforate 
into  the  nose,  and  can  then  be  mistaken  for  gumma.  The  malig- 
nancy of  palatal  carcinoma  is,  generally  speaking,  less  severe  than 
that  of  carcinoma  of  the  tongue  or  of  the  buccal  fundus;  the  lymph 
glands,  too,  remain  uninvolved  for  a  long  time. 

Treatment. — The  treatment  depends  upon  the  extent  of  the 
involvement.  If  the  superior  maxilla  is  involved,  partial  resection 
of  that  bone  is  the  best  remedy. 

Carcinoma  of  the  Uvula. — This  affection  is  particularly  rare,  but 
often  causes  extensive  metastases  in  the  cervical  lymph  glands. 


TUMORS  OF  THE  MAXILLJE  345 


TUMORS  OF  THE  MAXILLJE. 

Fibroma. — Fibromata  may  emanate  from  the  periosteum  of  the 
alveolar  processes  and  the  inner  wall  of  the  alveoli.  They  often 
contain  deposits  of  bone  and  lime,  and  are  very  hard.  They  are 
either  pedunculated  or  broadly  sessile,  and  may  press  the  teeth 
before  them  out  of  the  alveoli.  As  they  grow  larger  they  may 
bleed  and  ulcerate  from  mechanical  contacts.  There  is  another 
form  of  fibroma  which  starts  from  the  true  maxilla,  by  preference 
the  inferior.  It  grows  slowly,  causing  little  disturbance,  but  may 
attain  to  an  enormous  size.  Fibromata  originating  from  the 
interior  of  the  bone  affect  the  inferior  maxilla  mostly.  They  may 
distend  the  bone  considerably  and  perforate  through  the  thin 
osseous  shell.  In  doing  so  they  may  push  the  periosteum  before 
them  and  cause  neoplasms  of  bone,  so  that  the  entire  tumor  is 
covered  with  a  thin  osseous  layer  which  crepitates  upon  pressure. 
Fibromata  may  change  into  cartilaginous  or  mucoid  degeneration. 
Recurrences  may  follow  operation,  and  these  may  at  times  be  of 
a  sarcomatous  character.  In  the  superior  maxilla  the  fibromata 
may  advance  to  the  antrum  of  Highmore.  The  treatment  can 
only  be  operative. 

Chondroma. — Chondromata  do  not  occur  often  at  the  maxil- 
lary bones,  but  may  attain  to  an  enormous  size  and  destroy  the 
bone. 

Osteoma. — Osteomata  may  likewise  occur  at  the  maxillary 
bones.  They  fuse  with  the  surrounding  bone  without  forming  any 
sharp  border,  or  they  may  be  encapsulated. 

Odontoma. — Odontomata  are  tumors  as  hard  as  bone  which 
have  the  exact  appearance  of  dental  tissue.  The  enormous  enlarge- 
ment of  the  lower  maxilla  which  has  been  given  the  name  of  leonti- 
asis  ossea  is  very  rare.  At  times  exostoses  of  the  maxillary  bones 
are  met  with. 

Cysts. — Maxillary  cysts  are  mostly  due  to  disturbed  dental 
development.  The  root  cysts  result  from  epithelial  remnants 
which  have  been  left  behind  in  the  development  of  the  dental  roots. 
These  cysts  often  adhere  to  the  apex  of  the  dental  root  and  may 
attain  to  considerable  size.  The  cysts,  like  periostitic  abscesses, 
may  perforate  toward  the  mouth,  or  less  often  toward  the  outer 
skin.  Another  form  of  cyst  is  developed  through  cystic  degenera- 
tion of  normal  or  supernumerary  dental  cells.  It  occurs  in  the 
maxillary  body,  in  the  nose  or  orbit,  and  contains  dental  fragments 
in  various  stages  of  development.  Dermoid  cysts  are  very  rarely 
observed  in  the  submaxillary  bone. 

Adamantoma. — These  tumors  are  composed  of  enamel,  containing 
epithelium.  They  are  usually  located  in  the  lower  maxilla,  the 
substance  of  which  may  be  destroyed  thereby  to  a  considerable 


346  DISEASES  OF  THE  MOUTH 

extent.  Although  benign,  their  removal  necessitates  -extensive 
maxillary  resection. 

Sarcoma. — The  form  best  known  is  the  sarcoma  of  the  alveolar 
processes,  sometimes  called  epulis — a  giant-celled  sarcoma  which 
probably  originates  from  the  periosteum  without  forming  metas- 
tases, but  undergoes  frequent  recurrence.  Unless  operated  upon 
early,  it  may  attain  to  a  coosiderable  size,  destroying  large  portions 
of  the  bone.  The  subjective  symptoms  are  rather  severe,  because 
the  tumor  is  injured  by  mastication  and  is  then  apt  to  ulcerate. 
Removal  of  the  tumor  by  surgical  intervention  is  easy. 

Sarcoma  of  the  Maxilla. — Sarcoma  of  the  lower  maxilla  usually 
consists  of  spindle  cells,  that  of  the  upper  maxilla  of  round  cells, 
the  latter  being  distinguished  for  malignancy.  Sarcomata  of  the 
lower  maxilla  often  cause  severe  pain  by  exerting  pressure  upon 
the  mandibular  nerve.  The  object  of  the  treatment  is  to  remove 
these  growths  as  early  as  possible. 

Chondrosarcoma  and  Myxosarcoma  run  a  malignant  course,  as 
a  general  rule. 

Carcinoma. — Carcinoma  of  the  pavement  epithelium  frequently 
develops  at  the  alveolar  processes,  apparently  from  carious  teeth 
or  injuries  to  the  gums.  Central  maxillary  carcinoma  occurs  most 
frequently  in  the  upper  maxilla,  the  starting  point  usually  being 
the  mucosa  of  the  antrum  of  Highmore.  Central  carcinoma  of  the 
lower  maxilla  is  rarer.  The  treatment  consists  in  resection  of  the 
affected  bone. 


AFFECTIONS  OF  THE  PHARYNX. 

Acute  and  Chronic  Pharyngitis. — Acute  catarrh  of  the  pharynx 
occurs  in  infectious  diseases  and  in  acute  inflammations  of  the 
mucous  membrane  of  the  upper  air-passages;  it  may  also  be  due 
to  mechanical  or  chemical  injuries  to  the  pharyngeal  mucosa.  It 
subsides  when  the  underlying  cause  is  removed.  No  treatment  is 
required  except  in  aggravated  cases,  when  irrigation  and  gargling 
of  the  pharynx  with  astringents  and  antiseptics  (permanganate  of 
potassium,  tincture  krameria,  myrrh)  are  indicated.  When  the 
mucous  membrane  is  much  involved,  gargling  with  warm  chamo- 
mile or  mallow  tea  or  with  a  solution  of  cocain  will  have  a  pleas- 
ing effect.  Lozenges  containing  anesthesin,  orthoform,  or  cocain, 
slowly  dissolved  in  the  throat,  are  beneficial  (see  page  270) . 
.  Chronic  catarrh  of  the  pharynx  is  usually  a  manifestation  of 
inflammatory  processes  of  the  nose  and  the  nasopharyngeal  space, 
in  either  the  chronic  or  atrophic  form,  or  in  both  combined,  and 
usually  affects  the  posterior  and  lateral  parts  of  the  pharynx. 
Excessive  smoking,  vitiated  air,  and  sharp  irritating  food  or  bever- 
ages may  likewise  lead  to  chronic  catarrh.    The  symptoms  consist 


AFFECTIONS  OF  THE  PHARYNX  347 

of  an  unpleasant  scratching  sensation,  accumulation  of  mucus,  and 
slight  pain  in  the  pharynx. 

Treatment.— Nasal  catarrh  demands  attention.  Smoking  and 
the  breathing  of  vitiated  air  are  to  be  prohibited.  Local  application 
of  10-per-cent.  silver  nitrate  or  glycerin  iodid  (iodin  1,  potassium 
iodid  1,  glycerin  20)  is  indicated,  as  well  as  the  use  of  suitable 
gargles  and  inhalants. 

Follicular  Tonsillitis. — Follicular  tonsillitis  is  an  infectious  dis- 
ease and  rims  a  febrile  course.  It  often  begins  with  chills,  and  is 
characterized  by  ulcerous  deposits  in  which  the  follicles  are  filled 
with  caseous  cores  which  often  resemble  diphtheritic  or  scarlatinal 
angina.     In  most  cases  both  tonsils  are  affected. 

Treatment.- — When  there  is  fever  the  patient  is  put  to  bed. 
Fluid  diet,  Priessnitz  or  ice  compresses  around  the  neck,  and  cold 
baths  are  indicated.  Gargling  with  antiseptic  fluids  serves  to 
clean  and  irrigate  the  tonsils.  Severe  headache  may  be  relieved 
by  acetylsalicylic  acid  and  pyramidon.  Some  authors  recommend 
inunction  of  the  glandular  region  with  Crede's  silver  ointment 
(collargol).    Between  the  attacks  the  tonsils  should  be  enucleated. 

Parenchymatous  Tonsillitis,  Suppurative  Tonsillitis,  or  Quinsy. — 
This  disease  occurs  as  an  acute  affection,  with  the  formation  of  a 
tonsillary  abscess  which  is  usually  unilateral.  It  is  associated  with 
high  fever  and  often  with  considerable  disturbance  of  the  general 
condition,  severe  pain,  and  greatly  impeded  deglutition. 

Treatment. — The  patient  is  put  to  bed,  given  small  lumps  of  ice 
to  swallow,  and  encouraged  to  gargle  the  throat.  Ice  compresses 
are  applied.  Morphin  may  be  administered  when  the  pains  are 
very  severe.  Unless  the  abscess  perforates  spontaneously,  it  should 
be  promptly  incised;  the  tonsils  are  painted  with  cocain  solution 
and  an  incision  one  or  two  centimeters  deep  is  made,  parallel  to  the 
teeth,  toward  the  swelling.  If,  as  may  happen,  the  knife  does  not 
find  the  abscess,  the  latter  will  often  perforate  spontaneously  with- 
out further  assistance.  After  the  pus  has  been  evacuated  the  mouth 
should  be  frequently  rinsed  with  boric  acid  solution,  chamomile  tea, 
or  peroxid  of  hydrogen. 

Chronic  Tonsillitis. — Chronic  tonsillitis  may  develop  from  the 
acute  form,  but  it  also  occurs  without  any  previous  acute  inflam- 
mation. It  is  characterized  by  the  fact  that  it  causes  little  com- 
plaint, but  that  nevertheless  the  tonsils  persistently  contain  puru- 
lent and  caseous  cores  in  the  crypts.  These  cores  are  often  the 
source  of  rheumatic  and  septic  affections,  hence  the  importance  of 
examining  the  tonsils  carefully  in  cases  of  recurring  articular 
rheumatism,  endocarditis,  and  similar  affections.  In  most  of  these 
cases,  when  the  tonsils  are  affected  they  will  have  to  be  enucleated. 

Hypertrophy  of  the  Tonsils. — Many  individuals,  especially  chil- 
dren, suffer  from  hypertrophy  of  the  faucial  tonsils.  The  enlarge- 
ment may  give   rise  to  more  or  less  discomfort,  especially  by 


348  DISEASES  OF  THE  MOUTH 

impeding  the  nasal  inspiration  and  favoring  the  development  of 
acute  and  chronic  angina.  It  is  advisable,  therefore,  to  enucleate 
greatly  enlarged  tonsils.  Pure  air,  sea  air,  saline  baths,  arsenic, 
iron  and  iodin  often  have  a  favorable  effect  upon  the  adenoid 
vegetations  of  the  nasopharynx  and  hypertrophied  tonsils,  especially 
in  children. 

Retropharyngeal  Abscess. — These  abscesses  are  situated  in  front 
of  the  spinal  column,  and  are  attended  with  violent  pains  and,  in 
advanced  stages,  with  considerable  dyspnea.  They  are  the  cause 
of  the  well-known  typical  position  of  the  head,  and  can  be  palpated 
with  the  finger.  They  are  exceedingly  dangerous,  as  they  may 
lead  to  edema  of  the  glottis. 

Treatment. — The  abscess  is  opened  early  by  a  longitudinal 
incision,  preferably  without  anesthesia,  with  the  head  hanging- 
down  to  prevent  the  aspiration  of  pus.  Large  abscesses  which  are 
situated  toward  the  side  of  the  throat  may  be  incised  and  drained 
from  without. 

Tuberculous  Abscess. — Tuberculous  gravitation  abscess  originates 
from  necrosis  of  the  vertebra?  and  may  occur  in  the  pharynx.  The 
treatment  consists  in  evacuation  by  incision  from  without  and 
iodoform  injections. 


CHAPTER  XVI. 
DISEASES  OF  THE  ESOPHAGUS. 

According  to  general  acceptation,  the  esophagus  is  a  musculo- 
membranous  canal  bounded  superiorly  by  the  cricoid  cartilage. 
This  cartilage  and  the  adjoining  part  of  the  esophagus  are 
movable  upward  and  downward,  especially  when  the  head  is 
strongly  flexed  forward  or  backward.  The  lower  end  of  the 
esophagus  fuses  with  the  cardia  without  any  distinct  demarcation. 
The  physiologic  position  of  the  cardia  is  between  the  ninth  and 
eleventh  dorsal  vertebra?.  Thus  it  follows  that  the  position  of 
the  lower  end  of  the  esophagus  depends  upon  the  position  of  the 
cardia,  perhaps  also  that  of  the  diaphragm,  which  in  the  new-born 
lies  comparatively  high  and  in  older  persons  lower. 

The  esophagus  is  divided  into  a  cervical,  a  thoracic  and  an 
abdominal  section;  it  is  opportune  also  to  distinguish  between 
the  supra-  and  infra-bifurcated  parts — the  parts  above  and  below 
the  bifurcation  of  the  trachea.  Taking  into  consideration  the 
movability  and  changing  altitude  of  the  proximal  and  distal  ends 
of  the  esophagus,  the  average  length  of  this  organ  may  be  taken  at 
about  25  centimeters  (8  inches)  in  the  male,  somewhat  less  in 
the  female.  The  distance  from  the  upper  incisor  teeth  to  the 
cricoid  cartilage  is  15  centimeters,  from  the  teeth  to  the  cardia  about 
40  centimeters.  The  cervical  section  of  the  esophagus  measures 
about  5  centimeters,  the  thoracic  18  centimeters,  and  the  abdominal 
2  centimeters.  The  distance  from  the  teeth  to  the  crossing  point 
between  esophagus  and  left  bronchus  is  23  centimeters.  The  supra- 
bifurcated  part  of  the  esophagus  is  from  10  to  10.5  centimeters  in 
length. 

The  upper  end  of  the  esophageal  lumen  is  closed  by  a  sphincter, 
and  opens  but  slightly  even  under  exaggerated  inspiration.  This 
sphincteric  demarcation  between  the  pharynx  and  the  esophagus 
is  called  the  os  of  the  esophagus.  The  esophageal  walls  approach 
each  other  in  the  cervical  section,  while  in  the  infrabif  urea  ted 
section  there  is  an  open  lumen.  Owing  to  compression  of  the 
muscle  fibers  of  the  diaphragm  around  the  esophagus,  the  lumen 
is  changed  where  the  diaphragm  is  traversed.  This  change  con- 
sists either  in  a  diagonal  fissure — right  posterior  to  left  anterior — 
or  in  a  stellate  opening.  The  cardia,  when  at  rest,  shows  moderate 
tonic  contraction  and  is  closed.  The  esophageal  lumen  is  not  of 
uniform  width.  It  is  narrower  at  the  cricoid  cartilage,  the  aorta, 
the  bifurcation,  and  the  diaphragm. 


350  DISEASES  OF  THE  ESOPHAGUS 

The  esophagus  is  a  rather  thick-walled  muscular  tube,  invested 
with  a  thick,  coarse  layer  of  pavement  epithelium.  It  is  rather 
poor  in  glands  and  lymph  follicles,  in  contradistinction  to  the  com- 
plicated structure  of  the  gastro-intestinal  canal. 

Deglutition  Sounds. — The  two  deglutition  sounds  important  to 
the  clinician  were  described  by  Meltzer  thirty  years  ago.  They 
can  be  distinctly  heard  with  a  stethoscope  to  the  left  of  the  xiphoid 
process.  The  first,  or  squirting  sound,  can  be  heard  at  the  very 
beginning  of  the  act  of  deglutition.  It  is  a  short,  loud  sound  and 
indicates  the  absence  of  the  tonus  of  the  cardia.  The  second,  or 
pressing  sound,  can  be  heard  in  normal  cases  six  or  seven  seconds 
after  the  first  sound.  It  indicates  the  passage  of  the  swallowed 
fluid  through  the  cardia  when  the  latter  is  in  a  normal  state  of 
tonus;  it  is  loud  and  long.  These  sounds  assist  in  determining  the 
permeability  of  the  esophagus.  In  stricture  or  obstruction  the 
second  sound  is  delayed  or  absent. 

INSTRUMENTAL  EXAMINATION. 

Esophageal  Bougie. — The  esophageal  bougie  is  of  great  value  in 
the  diagnosis  of  diseases  of  the  esophagus,  revealing  the  existence 
of  obstruction  due  to  a  pocket,  narrowing  of  the  tube,  or  the  pres- 
ence of  a  foreign  body.  Before  using  the  stiff  sound,  the  much 
safer  soft-rubber  stomach  tube  should  be  employed.  Sjhould  there 
be  an  obstruction,  its  character  can  be  best  ascertained  by  exploring 
the  esophagus  with  the  olive-pointed  esophageal  bougie,  a  'flexible 
whalebone  shaft  with  a  screw  at  its  distal  end  to  which  a  metal 


Fig.   65. — Olive-pointed  esophageal  bougie. 

or  ivory  bougie  of  suitable  size  is  attached  (Fig.  65).  The  largest 
size  is  used  first.  With  the  instrument  in  the  right  hand,  the 
olivary  end  is  guided  carefully  back  into  the  esophagus.  When 
resistance,  other  than  at  the  cricoid  cartilage,  is  encountered,  the 
shaft  is  to  be  marked  at  the  incisor  teeth  with  the  finger  of  the 
left  hand,  for  locating  the  obstruction  on  withdrawal.  Smaller 
olive  points  are  then  employed  until  one  is  found  which  will  pass 
the  obstruction.  Much  force  should  never  be  exerted,  as  there  is 
always  danger  of  perforation.  In  case  of  obstruction  at  the  cricoid 
cartilage  the  patient  should  be  asked  to  swallow,  and  during  the 


INSTRUMENTAL  EXAMINATION  351 

act  the  bougie  will  easily  slip  through  the  esophagus  into  the 
stomach. 

Esophagoscope  and  Gastroscope. — Since  Mikulicz  in  1881  em- 
ployed a  long  straight  metal  tube  with  a  light  at  the  distal  end  to 
explore  the  esophagus  and  stomach,  great  progress  has  been  made 
in  both  esophagoscopy  and  gastroscopy.  Many  instruments  have 
been  devised— by  Killian,  Rosenheim,  Kraus,  Gottstein,  Kuttner, 
Kelling  and  Gluecksman  abroad,  and  Einhorn,  Jackson,  Plummer, 
Lerche  and  Janeway  in  this  country.  All  have  added  modifications, 
but  the  principle  of  the  esophagoscope  has  remained  the  same. 

The  great  value  of  the  esophagoscope  lies  in  the  fact  that  with 
its  aid  the  physician  is  able  to  see  with  the  naked  eye  all  parts  of 
the  esophagus  down  to  the  stomach.  Not  only  has  this  method  of 
direct  visual  inspection  assisted  greatly  in  diagnosis,  but  it  is  of 
material  aid  in  treatment,  as  in  the  use  of  special  forceps  for  the 
removal  of  foreign  bodies,  the  application  of  drugs  to  ulcerated 
surfaces,  curettes  for  the  removal  of  sections  for  microscopic  exami- 
nation, and  lens  attachments  for  photographing  pathologic  lesions. 

The  best  esophagoscope  is  that  of  Killian,  with  Bruning's  handle 
lamp.  Recently  William  Hill,  of  London,  has  modified  Killian's 
instrument,  making  an  esophago-gastroscope  by  adding  a  plane 
glass  window  at  the  proximal  end,  together  with  a  faucet  for 
attaching  a  rubber  bulb  for  purposes  of  inflation,  as  in  the  case 
of  the  pneumatic  sigmoidoscope  (Figs.  66  and  67).  By  means  of 
this  one  instrument  the  esophagus  is  examined  by  direct  vision, 
and  examination  of  the  stomach  by  indirect  vision  is  materially 
assisted  (by  inflation).  The  Hill  instrument  is  a  straight,  rigid 
tube  which  can  be  easily  passed  under  direct  vision  through  the 
esophagus  into  the  stomach.  When  the  stomach  is  to  be  examined, 
an  optical  tube  is  inserted  through  the  esophagoscope  and  the 
stomach  is  inflated  with  air. 

Care  and  a  working  knowledge  of  the  anatomy  and  pathology 
of  the  parts  with  which  the  esophagoscope  must  come  in  contact 
are,  of  course,  necessary  in  the  use  of  this  instrument,  the  expert 
manipulation  of  which  can  only  be  acquired  by  experience. 

When  the  esophagoscope  is  to  be  introduced,  the  patient,  sitting 
on  a  low  stool,  with  someone  in  a  chair  beside  him  supporting  his 
back,  throws  his  chest  somewhat  forward  and  his  head  as  far  back 
as  possible.  By  this  means  the  mouth,  pharynx  and  esophagus  are 
brought  into  line.  The  pharynx  is  thoroughly  anesthetized  with 
a  10-per-cent.  solution  of  cocain;  the  patient  is  instructed  not  to 
swallow  immediately  after  the  applications  are  made.  The  esopha- 
geal bougie,  extending  about  six  inches  beyond  the  end  of  the 
esophagoscope,  is  introduced  with  it,  the  patient's  head  being 
dropped  forward.  As  soon  as  the  tip  of  the  bougie  passes  over  the 
epiglottis,  the  patient  is  instructed  to  throw  his  head  back  as  far 
as  possible,    and   the  instruments  are   slowly   thrust  downward 


352 


DISEASES  OF  THE  ESOPHAGUS 


until  the  end  of  the  esophagoscope  is  felt  to  pass  over  the  cricoid 
cartilage.  This  sensation  is  a  very  definite  one  to  the  operator. 
The  bougie  is  then  slowly  removed,  while  the  esophagoscope  is 
held  in  position.  By  means  of  the  Briming  handle  lamp  the  light 
is  then-  thrown  into  the  esophagoscope,  the  further  progress  of 
which  is  under  the  constant  guidance  of  the  eye.  In  this  manner 
there  is  practically  no  danger  from  the  introduction. 

Before  inspecting  the  stomach,  unless  no  food  has  been  taken 
for  ten  hours  previously,  it  is  necessary  to  resort  to  lavage. 


Fig.  66. — Esophagoscope.     (Hill.) 


Fig.  67. — Gastroscope.     (Hill.) 


When  passing  the  inner  optical  tube  through  the  esophageal 
tube,  inflation  should  begin  before  the  end  of  the  inner  tube  reaches 
the  stomach,  to  prevent  soiling  the  lamp  and  window  of  the  peri- 
scope, which  would  obscure  the  vision.  The  whole  mucous  mem- 
brane of  the  stomach,  including  the  pylorus,  can  be  easily  inspected. 
With  a  fully  inflated  stomach  the  ruga?  and  convolutions  of  the 
mucosa  almost  entirely  disappear,  except  in  cases  of  chronic 
(alcoholic)  gastritis.  Engorged  veins  form  a  prominent  feature 
in  portal  obstruction.  Malignant  growths,  multiple  hemorrhagic 
erosions,  definite  chronic  peptic  ulcers,  hour-glass  contractions  and 
pyloric  stenosis  can  be  readily  recognized.  Rigidity  and  limited 
thickening  of  the  stomach  wall  is  suggestive  of  beginning  carcinoma. 


INFLAMMATION  OF  THE  ESOPHAGUS  353 

INFLAMMATION  OF  THE  ESOPHAGUS. 

Acute  Esophagitis. — Simple  acute  catarrhal  inflammation  of 
the  esophagus  is  caused  by  mechanical,  chemical  and  thermic 
irritations.  In  rare  cases  catarrh  of  the  pharynx  and  stomach 
may  spread  to  the  esophagus,  and  in  equally  rare  cases  acute 
bronchitis  and  laryngitis  may  be  complicated  by  esophagitis. 
Sometimes  the  latter  is  associated  with  acute  infectious  diseases 
(measles,  scarlet  fever,  typhoid,  variola).  In  acute  catarrh  there 
is  more  or  less  pronounced  hyperemia  of  the  mucous  membrane, 
with  loosening  and  desquamation  of  the  clouded  epithelium. 
Occasionally  the  swollen  glandlets  of  the  mucosa  protrude  in  the 
form  of  follicles  which  may  lead  to  slight  superficial  ulceration 
(esophagitis  f ollicularis) . 

Symptoms. — Probably  acute  esophagitis  occurs  oftener  than  it 
is  diagnosed,  for  the  reason  that  the  symptoms  are  obscured  or 
the  neighboring  organs  are  involved,  enshrouding  the  esophageal 
affection.  In  pronounced  esophagitis  there  are  distinct  piercing 
pains  which  may  assume  an  intensely  pressing  and  burning  char- 
acter, interfering  with  or  entirely  preventing  the  swallowing  of 
food,  particularly  solid  food.  Even  when  the  patient  is  at  rest 
there  is  a  dull  pain  deep  in  the  chest,  behind  the  sternum.  There 
is  often  considerable  thirst,  less  often  moderate  fever.  A  high 
degree  of  inflammation  is  often  accompanied  by  a  slimy,  tough 
secretion,  and  in  serious  cases  the  food  is  brought  up  at  once  after 
entering  the  esophagus.  The  affection  may  also  be  associated 
with  serious  general  nervous  manifestations  and  a  sensation  of 
considerable  angina.  Patients  are  anxious  to  avoid  any  movements 
of  the  head.  Pressure  upon  the  sternum,  palpation  of  the  dorsal 
vertebrae,  and  movements  of  the  body  may  be  extremely  painful. 
Introduction  of  the  sound  into  the  esophagus  is  always  very  painful 
in  these  cases  and  may  cause  spasm  of  that  organ.  Viewed  with 
the  esophagoscope,  the  mucous  membrane  appears  swollen  and 
relaxed,  the  vessels  being  injected. 

Treatment.- — If  the  affection  can  be  traced  to  a  definite  cause, 
the  latter  must  be  treated.  For  the  inflammation  and  thirst, 
iced  milk  and  small  pieces  of  ice  are  administered.  In  grave  cases 
food  should  not  be  given  by  mouth,  rectal  alimentation  being 
resorted  to;  gradually  liquid  and  semisolid  foods  are  allowed, 
until  by  degrees  normal  diet  is  resumed.  Hot  cataplasms  are 
applied  to  the  neck,  chest,  and  along  the  spine;  dry  heat  applied 
by  hot-water  bottles  or  thermophores  often  renders  good  service. 
Mustard  dough  sinapisms  or  capsicum  plasters  are  applied  between 
the  shoulder-blades.  Small  doses  of  morphin  are  injected  subcu- 
taneously  to  relieve  pain  and  reassure  the  patient. 

Chronic  Esophagitis. — Chronic  esophagitis  develops  but  rarely 
from  the  acute  form.  If,  however,  the  irritation  which  causes 
23 


354  DISEASES  OF  THE  ESOPHAGUS 

acute  esophagitis  repeats  itself  often,  it  may  lead  to  the  chronic 
form,  or  to  chronic  pharyngitis  and  chronic  gastritis.  An  impor- 
tant role  is  played  by  the  misuse  of  alcohol  and  tobacco,  so  that 
the  affection  is  most  frequently  found  in  elderly  men.  It  may 
also  be  due  to  persistent  venous  stasis  in  cardiac  and  pulmonary 
diseases,  or  it  may  occur  as  a  complication  with  other  esophageal 
affections,  particularly  in  stenosis  when  food  remnants  become 
stagnant  for  a  long  time.  Chronic  affections  of  the  stomach,  in 
which  acid  and  fermenting  masses  are  often  vomited,  lead  to 
chronic  catarrh  of  the  esophagus. 

Symptoms. — Pathologically,  there  are  venous  hyperemia,  uneven 
thickening  of  the  epithelium,  and  considerable  secretion  of  mucus. 
When  the  affection  has  persisted  for  several  years,  there  may  be 
considerable  hyperplasia  of  the  mucous  and  muscular  tissue. 
Polypoid  and  papillary  proliferations  of  the  mucous  membrane  are 
not  rare.  In  other  cases  the  affection  causes  but  slight  symptoms. 
In  pronounced  cases  pain  and  pressure  attend  the  act  of  swallowing. 
The  principal  symptoms  are  referable  to  the  upper  third  of  the 
esophagus,  the  walls  here  being  in  contact  with  each  other.     Often, 


Fig.  68. — Esophageal  syringe.     (Rosenheim.) 

when  there  is  great  sensitiveness,  the  food  is  brought  up,  perhaps 
with  an  admixture  of  blood.  Liquid  food  can  always  be  better 
swallowed  than  solid.  To  establish  the  diagnosis,  it  is  necessary 
to  resort  to  the  bougie  and  esophagoscope.  The  mucous  membrane, 
as  seen  through  the  latter,  is  of  a  whitish  cloudiness,  or  swollen 
and  dark  red,  covered  with  a  tough  mucous  secretion.  ^  The  bougie 
is  introduced  to  ascertain  whether  or  not  there  is  stricture. 

Treatment. — The  use  of  tobacco  and  alcohol  must  be  restricted. 
When  the  symptoms  are  quite  severe  the  food  should  be  soft, 
pappy  and  bland,  and  of  medium  temperature.  The  ingestion  of 
good* olive  oil  or  sweet  almond  oil  before  partaking  of  food  will 
facilitate  the  passage  of  the  latter.  Patients  should  beware  of 
contracting  colds.  Skin  irritation  applied  to  the  sternum  and 
spinal  column  (sinapisms,  tincture  of  iodin),  or  hot  foot-baths,  have 
sometimes  a  favorable  effect.  Local  treatment  is  usually  super- 
fluous. When  the  pain  is  considerable,  cocain  0.01  Gm.  (|  grain), 
anesthesin  or  orthoform  tablets  may  be  taken;  or  equivalent 
medication  may  be  introduced  by  means  of  Rosenheim's  esopha- 
geal syringe  (Fig.  68).  This  syringe  holds  1  to  1.5  Cc.  (15  to  25 
minims)  of  fluid,  and  is  provided  with  a  long  hard-rubber  tube 


INFLAMMATION  OF  THE  ESOPHAGUS  355 

which  may  be  bent  when  heated.  Cocain  solutions  (3  to  10  per 
cent.),  cucain  (3  to  5  per  cent.)  or  silver  nitrate  (1  to  3  per  cent.) 
may  be  injected  into  the  esophagus,  the  syringe  being  long  enough 
to  reach  the  cardia.  Another  method  of  introducing  antiphlogistic 
medication  into  the  esophagus  has  been  devised  by  Rosenheim; 
a  soft-rubber  stomach  tube  is  covered  with  a  paste  that  is  rigid 
when  cold,  but  is  dissolved  by  the  body  heat.  Such  pastes  are  the 
following: 

Gm.  or  Cc. 

1^— Acidi  tannici 0|  15-015  gr.  iij-viij 

Olei  theobromatis    ....  10  [0  Biiss 

Misce. 

1^ — Argenti  nitratis       .      .      .      .     0|2  — 0 1 5  gr.  iv-viij 

Olei  theobromatis    ....  10 10  5iiss 

Misce. 

The  tube  is  introduced  down  to  the  cardia  and  allowed  to  remain 
in  position  for  about  five  minutes,  by  which  time  the  paste  has 
dissolved  and  acts  immediately  upon  the  mucous  membrane. 

Exfoliative  Esophagitis. — This  affection  is  an  extreme  exaggera- 
tion of  acute  esophagitis,  inasmuch  as  the  tendency  to  desquamation 
of  the  epithelium  assumes  such  an  extreme  degree  that  large  flakes 
of  membrane  become  detached;  these  are  often  expelled  in  tubular 
pieces.  An  exudate  forms  beneath  the  injured  epithelium,  the  latter 
being  raised  and  detached  as  soon  as  there  is  sufficient  extraneous 
cause.  Before  the  membrane  is  definitely  expelled  there  may  be 
a  temporary  stenosis  of  the  lumen  accompanied  by  considerable 
dysphagia.  The  diagnosis  of  this  affection  cannot  be  made  until 
the  membrane  has  desquamated. 

Treatment.- — The  treatment  is  the  same  as  that  of  acute  esopha- 
gitis. The  use  of  the  bougie  is  not  advisable,  owing  to  the  danger 
of  perforation  or  tearing  off  pieces  of  epithelium. 

Fibrinous  Esophagitis. — Necrotic  fibrinous  inflammation  of  the 
esophageal  mucosa  develops  secondarily  in  grave  general  affections 
(sepsis,  variola,  cholera,  typhoid,  scarlatina,  measles,  tuberculosis, 
intestinal  diseases  of  children).  The  clinical  manifestations  of  this 
affection  are  usually  so  veiled  by  the  general  affection  as  to  be 
completely  overlooked,  especially  if  there  is  a  simultaneous  affec- 
tion of  the  tonsils,  pharynx  or  larynx.  Hemorrhages  from  the 
esophagus  and  expulsion  of  membranous  shreds  may  point  to  the 
nature  of  the  disease.  The  fibrinous  inflammation  may  lead  to 
extensive  ulceration,  and  consequently  to  gradual  constriction  of 
the  esophagus  after  the  affection  has  run  its  course.  The  prog- 
nosis is  always  serious. 

Treatment. — The  treatment  is  directed  toward  the  primary  dis- 
ease. For  the  local  lesion  it  is  symptomatic  and  expectant,  just 
like  that  of  simple  esophagitis.  The  use  of  bougies  or  sounds  is 
not  permitted  under  any  circumstances. 


356  DISEASES  OF  THE  ESOPHAGUS 

Phlegmonous  Esophagitis. — This  disease,  which  is  a  rare  one, 
may  assume  either  the  circumscribed  or  the  diffuse  form.  It  may 
originate  from  simple  acute  or  follicular  esophagitis,  diphtheritic 
esophagitis,  injuries  inflicted  by  sounds  or  foreign  bodies,  of  the 
spreading  of  phlegmonous  processes  in  the  stomach  and  pharynx; 
or  from  without  by  perforation  of  peri-esophageal  pus  foci,  glandu- 
lar abscesses,  perichondritis,  caseous  lymph  glands,  or  vertebral 
pathologic  processes,  into  the  external  layers  of  the  esophagus.  In 
these  latter  cases  the  process  diffuses  in  the  submucosa  and  per- 
forates through  the  mucosa  into  the  esophageal  lumen. 

Phlegmonous  esophagitis  begins  as  a  suppurative  inflammation 
of  the  submucosa,  with  destruction  of  the  tissue,  and  circumscribed 
or  very  extensive  collections  of  pus  under  the  mucous  membrane. 
The  undermined  mucosa  may  then  be  pushed  into  the  lumen  of 
the  esophagus  to  such  an  extent  as  to  cause  a  constriction.  Should 
the  pus  perforate  into  the  esophageal  lumen,  this  may  lead  to 
healing.  It  may  also  lead  to  fistular  defects  resembling  diver- 
ticula, which,  however,  will  not  cause  any  particular  disturbance. 
Perforation  through  the  muscularis  of  the  esophagus  into  the 
mediastinum  or  the  thoracic  cavities  does  not  easily  occur. 

Aside  from  grave  injury  to  the  general  condition,  there  are 
fever,  dysphagia,  and  occasionally  chill,  in  many  cases  nausea 
and  dyspnea.  The  circumscribed  phlegmons  are  prognostically 
favorable. 

Treatment. — The  treatment  may  at  first  be  purely  symptomatic. 
Ice  and  iced  milk  should  be  freely  prescribed;  rectal  feeding  may 
have  to  be  resorted  to.  Morphin  is  often  indispensable.  If  there 
is  reason  to  suspect  a  phlegmonous  affection,  the  bougie  may  be 
carefully  introduced  in  order  to  forcibly  open  any  possible  abscess 
and  evacuate  the  pus.  This  is  a  desirable  proceeding,  since 
spontaneous  rupture  is  often  considerably  delayed,  the  patients 
becoming  in  the  meantime  much  debilitated.  If  at  all  possible 
these  cases  should  be  examined  with  the  esophagoscope,  the  abscess 
opened  under  guidance  of  the  eye,  and  any  foreign  body  removed 
as  the  cause  of  the  trouble. 


INFECTIOUS  DISEASES  IN  THE  ESOPHAGUS. 

Diphtheria. — Diphtheria  of  the  pharynx  and  larynx  may  in  rare 
cases  spread  to  the  esophagus,  although  this  organ  possesses  such 
a  degree  of  immunity  toward  diphtheria  that  the  disease  may 
spread  to  the  stomach  without  affecting  it  at  all.  Diphtheria  of 
the  esophagus  may  easily  be  overlooked  in  the  presence  of  diph- 
theria of  the  larynx.  The  symptoms  are  the  same  as  in  non- 
diphtheritic  inflammation  of  the  esophagus. 

Treatment. — Antidiphtheritic  and  symptomatic. 


BURNS  AND  CORROSIONS  OF  THE  ESOPHAGUS  357 

Variola. — Tn  variola  an  exanthom  often  develops  on  the  esophageal 
mucosa  in  the  form  of  hyperemic,  infiltrated,  granular  efflorescences 
which  may  become  superficially  ulcerative.  These  changes  will 
disappear  with  the  disappearance  of  the  original  affection. 

SKIN  DISEASES  IN  THE  ESOPHAGUS. 

Pemphigus  and  herpes  zoster  have  been  observed  in  the  esophagus 
by  means  of  the  esophagoscope.  The  treatment  consists  in  non- 
irritating  liquid  diet,  injections  of  cocain  or  eucain,  and  adminis- 
tration of  morphin. 

BURNS  AND  CORROSIONS  OF  THE  ESOPHAGUS. 

Burns  of  the  esophagus  may  occur  through  steam  or  hot  liquids 
or  solids.  Esophageal  burns  due  to  steam  are  caused  mostly  by 
boiler  explosions.  Scalding  and  burning  of  the  esophagus  by  hot 
liquids  causes  considerable  swelling  and  reddening  of  the  mucous 
membrane,  which  may  become  detached  in  shreds.  The  areas 
denuded  of  epithelium  may  slough,  erode  or  ulcerate.  Another 
possible  sequel  is  constriction  of  the  lumen  due  to  scar  formation. 

Corrosion  of  the  esophagus  occurs  through  acids,  notably  sul- 
phuric acid,  and  caustic  alkalis,  which  are  swallowed  with  the  inten- 
tion of  poisoning  or  by  accident.  In  light  cases  the  epithelium 
is  destroyed  and  desquamated — an  injury  which  is  easily  remedied. 
In  serious  cases  the  corroded  mucosa  becomes  acutely  inflamed 
and  necrotic;  the  necrotic  parts  are  desquamated,  and  there  is 
intense  ulceration  which  may  be  followed  by  a  phlegmon  of  the 
esophagus.  When  the  ulcers  gradually  heal  from  the  margin,  the 
final  result  will  be  extensive  scar  formation  and  constriction  of  the 
esophagus.  In  grave  cases  the  esophageal  wall  becomes  necrotic 
in  all  its  layers  and  is  changed  to  a  pappy  tissue,  leading  invariably 
to  death.  The  physiologically  narrow  regions  of  the  esophagus  are 
injured  most  by  the  corrosive  fluid. 

Immediately  upon  swallowing  a  corrosive  substance,  a  violent 
burning  pain  under  the  sternum  is  experienced,  followed  by  retch- 
ing of  pappy,  hemorrhagic  masses.  Thirst,  fever  and  collapse 
ensue.  Unless  the  condition  proves  rapidly  fatal,  the  pain  grad- 
ually diminishes  after  twenty-four  hours.  After  a  time  deglutition 
becomes  less  painful,  and  the  injury  may  undergo  healing.  It 
may  be  possible  for  a  patient  to  swallow  small  pieces  of  solid  food; 
but  as  soon  as  scars  begin  to  form,  the  lumen  is  constricted  and 
swallowing  is  again  interfered  with.  This  undesirable  result 
cannot  be  avoided  except  in  light  cases. 

Statistics  have  shown  that  more  than  half  the  cases  of  sulphuric 
acid  poisoning  terminate  fatally,  and  about  25  per  cent,  of  alkali 
poisoning  cases.     In  more  than  one-third  of  the  survivors  of  sul- 


358  DISEASES  OF  THE  ESOPHAGUS 

phuric  acid  poisoning,  and  more  than  one-half  of  those  who  sur- 
vive alkali  poisoning,  grave  constrictions  result.  About  one-third 
of  the  strictured  cases  die  as  a  consequence  of  the  strictures. 

Treatment. — In  acid  poisoning,  magnesia  is  administered  by 
the  teaspoonful  in  iced  milk.  In  alkali  poisoning,  diluted  acetic 
or  citric  acid  is  given  in  iced  water.  These  remedies  must,  of 
course,  be  given  immediately  after  the  poisoning,  to  have  a  neutral- 
izing effect.  Otherwise  there  is  nothing  but  symptomatic  treatment 
to  overcome  the  inflammation,  such  as  the  swallowing  of  small 
pieces  of  ice,  application  of  ice-bags  to  the  chest  and  neck,  narcotics, 
rectal  feeding,  and  restriction  of  mouth  feeding  to  liquid  foods. 
Solid  food  is  not  permitted  for  a  long  time,  even  in  favorable 
cases.  When  there  is  considerable  dysphagia  after  the  acute 
manifestations  have  subsided,  the  chest  and  the  spine  are  to  be 
painted  with  tincture  of  iodin;  or  a  mustard  poultice  may  be 
applied.  No  instrument  should  be  introduced  in  fresh  cases  of 
corrosive  esophagitis,  as  long  as  necrosis  or  fresh  ulcerations  are 
present,  which  often  means  for  three  or  four  weeks.  Epinephrin, 
5  to  10  drops  of  the  1:1000  solution  in  a  teaspoonful  of  water, 
gives  great  relief.    The  stricture  is  to  be  treated  later  (see  page  365) . 

It  is  not  necessary  to  resort  to  gastrostomy  in  each  case  of  fresh 
corrosion,  although  some  authors  advise  it.  This  operation  becomes 
necessary  when  the  injury  runs  a  chronic  course  and  when  large 
pieces  of  the  esophagus  are  expelled,  with  the  probability  of  deep 
ulcerations  and  extensive  cicatrization.  Gastrostomy  is  also 
necessary  if,  at  an  early  stage,  acute  swelling  causes  complete 
occlusion  of  the  esophagus,  or  when  the  formation  of  peri-esophageal 
abscesses  is  suspected.  In  these  cases  the  stomach  fistula  is 
necessary,  that  the  strength  of  the  patient  may  be  maintained  and 
the  esophagus  spared. 

ULCERS  OF  THE  ESOPHAGUS. 

Gangrenous  Ulcers. — Gangrenous  processes  in  the  neighborhood 
of  the  esophagus  (pulmonary  gangrene,  noma,  gangrene  of  the 
tonsils)  may  spread  to  the  esophagus  and  cause  grave  destruction, 
but  this  is  a  rare  occurrence. 

Gangrenous  ulcers  may  also  be  due  to  pressure  upon  the  esophagus 
from  within  or  without.  Impacted  foreign  bodies  may  render 
the  mucous  membrane  and  the  deeper  layers  necrotic  by  persis- 
tent pressure;  permanent  sounds  may  exert  a  similar  effect;  ulcers 
or  aneurysms  may  cause  circumscribed  gangrene  by  pressure  upon 
the  esophageal  wall  from  without. 

Decubital  Ulcers. — Decubital  ulcers  are  caused  in  the  esophagus 
in  the  same  manner  as  in  any  other  part  of  the  body  when,  aside 
from  any  local  circulatory  impediment,  there  is  a  tendency  to  the 
formation  of  such  ulcers.     Such  a  tendency  may  be  due  to  old 


ULCERS  OF  THE  ESOPHAGUS  359 

age,  general  affections  (infectious  diseases),  or  neurotic  affections. 
Generally  speaking,  there  is  only  one  point  in  the  esophagus,  or 
rather  in  the  lower  part  of  the  pharynx,  which  inclines  to  the 
formation  of  these  ulcers,  and  that  is  at  the  cricoid  cartilage.  In 
patients  suffering  from  a  serious  disease,  or  who  are  bed-ridden, 
as  well  as  in  cases  of  senility,  the  broad,  thick  part  of  the  cricoid 
cartilage  lies  directly  upon  the  posterior  pharyngeal  wall,  especially 
when  the  body  is  in  the  horizontal  position.  This  persistent 
pressure  causes  a  decubital  ulcer  of  the  mucosa  just  at  the  point 
where  it  covers  the  cricoid  cartilage,  and  another  one  precisely 
opposite  on  the  mucosa  of  the  posterior  pharyngeal  wall — the 
latter  being,  to  a  certain  extent,  a  counter-product  of  the  ulcer 
of  the  cricoid  cartilage.  These  ulcers  occur  only  in  the  last  few 
days  or  weeks  of  life,  and  therefore  do  not  involve  the  question  of 
treatment. 

Tuberculous  Ulcers. — Esophageal  tuberculosis  occurs  as  a  con- 
comitant manifestation  of  grave  tuberculosis  in  other  organs. 
Usually  there  are  superficial  ulcers  of  various  sizes,  with  either 
a  smooth  or  a  rough  base.  On  this  ulcerous  base,  at  the  margins, 
or  in  the  neighborhood  of  the  ulcers,  characteristic  tubercles  can 
be  seen  underneath  the  epithelium  which  as  yet  is  intact.  The 
affection  is  probably  due  in  most  cases  to  perforation  of  caseous 
lymph  glands  into  the  esophagus.  It  certainly  is  possible,  by  way 
of  exception,  for  tuberculous  sputum  to  cause  the  infection,  espe- 
cially when  the  mucosa  is  already  injured  from  other  causes.  The 
disease  may  run  its  course  without  causing  any  symptoms,  but, 
on  the  other  hand,  it  may  give  rise  to  pains  and  dysphagia.  There 
is  also  a  possibility  of  esophageal  stricture  developing  in  the  course 
of  the  disease.  The  diagnosis  can  be  made  with  the  esophagoscope 
(see  page  352,  Figs.  66  and  67).  The  prognosis,  as  a  matter  of 
course,  is  unfavorable. 

Treatment. — Treatment  is  purely  symptomatic  and  consists  in 
injections  of  a  3-  to  10-per-cent.  cocain  solution  with  the  esopha- 
geal syringe  (Fig.  68)  prior  to  the  ingestion  of  food;  or  the  admin- 
istration of  oil,  or  of  anesthesin,  orthoform,  or  bismuth  subnitrate 
in  water,  before  eating.  The  food  should  be  liquid,  pappy  and 
non-irritating. 

Syphilitic  Ulcers. — It  is  an  established  fact  that,  in  the  tertiary 
period  of  acquired  syphilis,  submucous  gummata  and  diffuse  ulcerat- 
ing syphilitic  infiltrations  occur,  in  rare  cases,  in  the  esophagus. 
The  gummata  may  either  ulcerate  or  shrink  to  fibers.  Congenital 
syphilis,  too,  appears  to  be  capable  of  causing  esophageal  infection. 
It  is  not  yet  certain  whether  the  esophageal  mucosa  may  be  affected 
in  the  secondary  stage.  The  symptoms  are  dysphagia  and  painful 
deglutition.  When  the  infiltrates  and  ulcers  heal,  extensive  scars 
and  strictures  may  remain. 


360  DISEASES  OF  THE  ESOPHAGUS 

Diagnosis.- — The  diagnosis  is  based  upon  the  presence  of  other 
syphilitic  symptoms,  upon  the  results  of  antisyphilitic  treatment, 
or,  occasionally,  upon  esophagoscopic  observations.  The  Wasser- 
mann  test  assists  in  the  diagnosis. 

Treatment. — The  treatment  is  antisyphilitic — iodids,  mercury,  and 
arsphenamine  (see  Chapter  XXVIII).  If  there  is  any  tendency 
to  stricture,  the  use  of  the  sound  is  indicated. 

Peptic  Ulcere — As  a  matter  of  fact,  ulcers  may  occur  in  the 
esophagus  which  entirely  correspond  to  the  round  ulcers  of  the 
stomach.  The  seat  of  these  peptic  ulcers  is  in  most  cases  the 
lower  third  of  the  esophagus.  They  are  caused  by  the  acid  gastric 
juice,  and  occur  principally  in  persons  with  hyperacidity,  as  a 
consequence  of  frequent  eructations  with  regurgitation  of  the  acid 
gastric  contents,  or  from  the  escape  of  the  acid  gastric  juice  from 
the  stomach  into  the  esophagus  due  to  defective  closure  of  the 
cardia.  They  may  be  single  or  multiple,  or  they  may  occur  simul- 
taneously with  gastric  and  duodenal  ulcers.  Peptic  esophageal 
ulcers  are  round,  like  gastric  ulcers,  of  varying  sizes,  have  smooth 
edges,  contain  brownish-black  tissue  shreds  at  the  base,  and, 
like  gastric  ulcers,  have  a  tendency  to  grow  into  the  deep  parts. 
Such  an  ulceration  may  be  exceedingly  large,  or  it  may  grow  around 
the  esophagus  circularly,  giving  rise  to  pouches  and  valves,  simu- 
lating stenosis.  As  a  rule  the  ulcers  tend  to  heal  by  cicatriza- 
tion. Small  ulcers  heal  without  any  particular  sequelae,  while 
large  ones  may  result  in  stricture.  Very  deep  ulcers  may  easily 
cause  adhesions  with  surrounding  parts  and  perforation  into  the 
mediastinum,  pleura,  etc.  As  a  matter  of  course  such  an  ulcer 
may  degenerate  into  a  carcinoma. 

Symptoms. — The  chief  symptom  of  the  ulcer  is  pain  in  swallow- 
ing, which  is  usually  felt  at  the  level  of  the  xiphoid  cartilage.  Solid 
food  usually  gives  greater  pain  than  liquid.  There  may  also  be 
pain  after  eating.  Sounding  of  the  esophagus  causes  pain  at  the 
seat  of  the  ulcer.  Sometimes  the  stomach  is  the  seat  of  severe 
pain.  There  is  often  a  tendency  to  pyrosis,  sour  eructation,  and 
vomiting.  Hematemesis  and  hemorrhagic  stools  may  occur,  as 
in  gastric  ulcer.  The  ingestion  of  food  may  become  so  difficult 
that  the  patients  lose  flesh  rapidly.  Under  certain  circumstances 
the  ulcer  is  visible  with  the  esophagoscope;  otherwise  the  diagnosis 
is  always  difficult. 

Treatment.- — It  is  advisable  for  the  patient  to  forego  eating  for 
a  number  of  days,  depending  entirely  upon  rectal  feeding.  This 
should  be  followed  by  ulcer  treatment  according  to  Leube  or 
Lenhartz  (see  Chapter  XXV) .  This  treatment  is  carried  out  as 
in  gastric  ulcer,  and  includes  absolute  rest  in  bed.  Hyperacidity 
is  energetically  counteracted  by  mineral  waters,  the  administration 
of  alkalis,  and  liberal  doses  of  belladonna — 0.01  to  0.03  Gm.  (|  to  \ 
grain).     Pain  is  relieved  by  cocain  tablets  0.01  Gm.   (£  grain), 


STRICTURE  OF  THE  ESOPHAGUS  361 

anesthesin  in  powder  or  tablets  0.03  Gm.  i\  grain),  or  orthoform 
0.03  Gm.  (§  grain),  or  one  of  tin*  last  two  in  conjunction  with 
bismuth.  In  grave  cases,  when  other  measures  fail  and  the  patient 
is  losing  ground  through  laek  of  food,  a  gastrostomy  is  required. 
When,  after  healing  of  the  ulcer,  there  are  symptoms  of  stricture, 
the  sound  must  be  regularly  used  (see  page  365). 

VEGETABLE  AND  ANIMAL  PARASITES. 

Actinomycosis. — Primary  actinomycosis  of  the  esophagus  is  very 
rare.  The  diagnosis  is  made  with  the  esophagoscope,  and  is,  of 
course,  comparatively  easy  when  infected  material  can  be  removed 
from  the  uleer. 

Thrush. — Thrush  of  the  esophagus  occurs  comparatively  often. 
It  is  the  result  of  direct  spreading  of  a  thrush  infection  of  the 
mouth  and  fauces  (see  page  309)  to  the  esophagus,  where  it  grows 
exactly  as  on  the  oral  mucosa,  so  that  the  mycelia  often  extend 
through  the  mucous  membrane  and  into  the  muscle.  The  in- 
fected areas  appear  on  the  esophageal  mucosa  either  as  small 
flat  or  lumpy  deposits,  or  as  striated  irregular  plaques  and  mem- 
branes; or  else  the  vegetation  is  so  extensive  that  the  esophagus 
is  lined  with  it  for  long  distances  or  throughout  its  entire  length, 
or  it  may  be  filled  with  dense,  compact  thrush  masses  to  such  an 
extent  that  occasionally  tubular  casts  of  the  esophagus  are  expelled. 
The  mucosa  underneath  the  proliferations  is  inflamed.  After  the 
plaques  have  desquamated,  a  flat  loss  of  substance  remains. 

Esophageal  thrush  causes  no  symptoms  except  when  markedly 
developed,  and  it  may  be  impossible  to  make  the  diagnosis  during 
the  patient's  lifetime.  Swallowing  is  apt  to  become  difficult  or 
impossible,  especially  in  children.  Since  extensive  development 
occurs  only  in  the  presence  of  grave  general  infections  and  in 
diabetics,  the  question  of  treatment  need  hardly  be  considered. 

Animal  Parasites. — Leeches,  flies,  ascarides  and  icasps  have  been 
found  in  the  esophagus.  In  one  case  a  wasp  sting  caused  serious 
esophagitis.  Occasionally,  the  transversely  striated  musculature 
of  the  esophagus  contains  free  or  encapsulated  trichinae  when 
general  trichinosis  is  present  (see  Chapter  LII). 

STRICTURE  OF  THE  ESOPHAGUS. 

The  various  forms  of  esophageal  stricture  may  be  classified  as 
follows: 

1.  Stricture  due  to  an  affection  of  the  esophageal  wall  (neoplasms; 
cicatricial  strictures  following  corrosions  and  ulcerous  processes; 
diverticula). 

2.  Stricture  due  to  occlusion  of  the  lumen  (foreign  bodies,  thrush). 

3.  Stricture  due  to  compression  of  the  esophagus  from  without 
(affections  of  the  neighboring .  organs) . 


362  DISEASES  OF  THE  ESOPHAGUS 

4.  (a)  Spasm  of  the  esophagus;  (6)  Dilatation  of  the  esophagus. 

5.  Congenital  stricture. 

Neoplasms  in  the  Esophagus. — Papilloma.— Papillomata  in  the 
esophagus  possess  merely  an  anatomic  interest,  as  they  cause  no 
symptoms  whatever.  They  are  from  pinhead  to  pea  size,  grow 
on  the  surface  of  the  mucosa,  and  originate  from  elongation  of 
the  papillae  of  the  mucosa  and  thickening  of  their  epithelial  cover- 
ing. Anatomically  they  correspond  to  the  ordinary  warts  of  the 
skin,  and  are,  for  the  most  part,  found  in  old  people,  either  isolated 
or  in  large  numbers,  and  often  accompanied  by  carcinoma. 

Fibroma. — Fibromata  are  the  most  frequent  of  benign  neoplasms 
of  the  esophagus.  They  start  from  the  submucosa  and  muscularis 
and  become  more  or  less  prominent  tumors,  of  soft  consistency 
and  an  uneven  lobular  surface.  These  fibromata  never  cause  com- 
plete occlusion  of  the  esophagus,  owing  to  their  softness  and  the 
fact  that  the  opposite  part  of  the  esophageal  wall  evades  the 
tumor,  so  that  most  of  the  food  can  pass  unhindered.  Fibromata 
may  easily  cause  symptoms  if  they  grow  in  pedunculated  form 
on  the  surface  and  represent  polypi,  as  is  often  the  case.  They 
occasionally  attain  to  such  a  considerable  size  that  they  are  sure 
to  cause  disturbance,  such  as:  painful  pressure  in  the  chest, 
increased  during  meals;  pressure  on  the  trachea,  interfering  with 
breathing:  or  dysphagia  independent  of  this  symptom.  The  polypi 
are  frequently  located  in  the  upper  third  of  the  esophagus,  and  the 
act  of  vomiting  or  retching  may  thrust  them  upward,  causing 
pressure  upon  the  epiglottis  and  threatening  suffocation.  The 
polypi  may  even  become  palpable  and  visible  in  the  pharynx  and 
mouth — a  fact  of  diagnostic  importance.  Sometimes  inspection 
through  the  esophagoscope  renders  the  diagnosis  clear;  or  it  may  be 
necessary  to  excise  a  small  piece  of  the  tumor  and  examine  it  micro- 
scopically. These  benign  polypi  may  cause  certain  dangers,  owing 
to  their  location,  necessitating  their  removal.  The  treatment  is 
entirely  surgical. 

Other  Benign  Neoplasms. — Lipomata  have  been  observed  in  the 
shape  of  sharply  demarcated  spheroidal  tumors  or  polypi;  also 
pedunculated  or  unpedunculated  myomata,  the  former  causing 
manifestations  similar  to  those  of  fibrous  polypi.  Idiopathic 
hypertrophy  of  the  esophageal  musculature  has  likewise  been 
observed.  The  mucous  glands  sometimes  develop  into  cysts.  All 
these  kinds  of  tumor  hardly  cause  any  clinical  manifestations. 
Dermoids,  which  in  most  cases  occur  in  the  lowest  part  of  the 
pharynx,  are  exceedingly  rare. 

Carcinoma. — Among  tumors  of  the  esophagus,  carcinoma  is  the 
most  frequent.  In  the  great  majority  of  cases  it  consists  of  pave- 
ment epithelium.  The  tumor  originates  either  from  the  deep 
epithelial  layers  of  the  mucous  membrane  or  from  the  epithelium 
of  the  excretory  ducts  of  the  mucous  glands.     The  process  of 


STRICTURE  FROM  CARCINOMA  363 

extension  is  more  often  annular  than  in  the  form  of  separated 
areas  of  erosion.  The  surface  of  the  carcinoma  is  nearly  always 
ulcerated,  and  the  surrounding  mucous  membrane  is  in  most  cases 
chronically  inflamed.  The  esophagus  is  never  affected  in  its  entire 
length.  Points  of  predilection  for  the  development  of  carcinoma 
are  the  region  of  the  bifurcation  of  the  trachea,  and  that  part  of 
the  esophagus  which  is  surrounded  by  the  diaphragm  (hiatus 
ceso  phage  us).  Most  esophageal  carcinomata  are  located  at  the  level 
of  the  bifurcation  of  the  trachea.  Predisposing  factors  favoring  the 
development  of  carcinoma  are  scars,  excoriations,  and  esophageal 
ulcers.  Further  contributing  causes  are  chronic  mechanical,  chemical 
or  thermic  irritations,  stirring  up  the  points  of  predilection  above 
referred  to,  which  represent  the  physiologic  constrictions  of  the 
esophagus.  For  this  reason,  alcoholics  are  especially  liable  to 
the  affection.  The  majority  of  cases  are  furnished  by  the  male 
sex,  mostly  between  the  ages  of  forty  and  sixty. 

If  food  lodges  and  is  retained  above  the  carcinoma,  dilatation 
with  hypertrophy  of  the  musculature  may  develop;  but  this  does 
not  often  happen,  because  in  most  cases  the  food  is  promptly 
vomited.  Dilatation  may  also  occur  above  the  carcinomatous 
stricture,  if  any  food  passing  through  is  not  carried  onward  by 
peristalsis. 

Symptoms. — The  first  and  most  important  symptom  is  inter- 
ference with  deglutition.  In  most  cases  this  disturbance  develops 
quite  gradually,  commencing  with  slight  pressure  behind  the  ster- 
num when  solid  morsels  are  swallowed.  The  difficulty  increases 
more  or  less  rapidly  until  nothing  but  thin  liquids  can  be  swallowed, 
and  even  these  not  without  effort.  Again,  dysphagia  may  set  in 
quite  suddenly,  or  it  may  undergo  rapid  improvement  owing  to 
necrotic  decay  of  large  tumor  masses.  As  the  stricture  increases, 
the  food  is  often  vomited  together  with  mucus,  saliva,  and  blood. 
The  presence  of  much  pain  suggests  further  spreading  of  the 
carcinoma  and  metastatic  formations  which  exert  pressure  upon 
neighboring  nerve  trunks.  The  sensation  of  hunger,  often  experi- 
enced, gives  way  to  pronounced  anorexia.  In  most  cases  there  is 
much  thirst.  As  the  tumor  grows,  involving  neighboring  organs, 
there  may  be  hoarseness,  aphonia,  dyspnea,  and  paroxysms  of  pain. 
It  not  infrequently  happens  that  there  is  unilateral  paralysis  of 
the  vocal  cords  which  can  only  be  recognized  with  the  laryngo- 
scope. Furthermore,  the  carcinoma  may  perforate  into  the  trachea, 
mediastinum,  or  large  vessels,  fatal  hemorrhage  resulting. 

Diagnosis. — The  diagnosis  is  made  from  the  anamnesis;  from 
the  sound  findings  which  will  establish  the  presence  and  seat  of 
the  stricture;  from  Roentgen-ray  examinations  (Plate  XII,  Figs. 
1  and  2)  which  reveal  its  length;  or  through  the  esophagoscope 
revealing  the  ulcerating  mucosa.  Sometimes  small  particles  of 
the  tumor  can  be  withdrawn  with  the  tube  or  the  fenestrated  sound 


364  DISEASES  OF  THE  ESOPHAGUS 

for  purposes  of  microscopic  examination,  or  small  parts  may  be 
excised  in  the  esophagoscope.  If  stagnant  food  remnants  can  be 
withdrawn  from  above  the  stricture,  they  will  be  found  free  from 
hydrochloric  acid,  and  the  presence  of  blood  can  be  microscopi- 
cally demonstrated,  also  pus  corpuscles,  and  often  many  long 
bacilli. 

The  affection  usually  terminates  fatally,  on  the  average  after 
about  ten  months.  Surgery  alone  can  bring  about  complete  relief. 
Recently  radium  has  been  found  to  be  of  some  benefit,  retarding 
the  development  of  the  neoplasm  (see  page  550) . 

Sarcoma. — Sarcoma  as  a  primary  affection  is  exceedingly  rare, 
but  as  a  secondary  manifestation  it  may  spread  from  neighboring 
sarcomatous  organs.  The  symptoms  resemble  those  of  carcinoma. 
The  diagnosis  is  assured  by  the  esophagoscope  and  excision  for 
the  laboratory. 

Cicatricial  Stricture.— It  has  already  been  stated  that  cicatricial 
strictures  occur  after  corrosion  of  the  esophagus  and  cicatrization 
of  ulcerous  processes  (tuberculosis,  syphilis,  peptic  ulcer). 

Treatment  of  Esophageal  Stricture.— In  the  treatment  of  stricture 
of  the  esophagus,  the  use  of  the  sound  is  of  prime  importance. 
When  the  tip  of  the  olive-pointed  bougie  meets  an  obstruction, 
this  is  due  either  to  a  pocket  or  to  narrowing  of  the  lumen 
of  the  esophagus.  Under  such  circumstances  Mixter's  method 
of  using  silk  thread  as  a  guide  to  the  bougie  should  be  adopted. 
The  patient  is  allowed  to  swallow  gradually  six  yards  or  more  of 
strong  silk  thread.  After  the  thread  has  passed  through  the 
different  segments  of  the  intestine,  it  cannot  very  easily  be  with- 
drawn through  the  mouth.  Traction  on  the  upper  end  makes  the 
thread  tense,  and  the  olive-pointed  sound  is  now  passed  on  the 
thread  (Fig.  72).  When  introduced  on  a  taut  thread,  the  sound 
follows  the  axis  of  the  lumen  of  the  esophagus.  By  varying  the 
tension  on  the  thread,  obstruction  from  pocketing  and  obstruction 
from  actual  narrowing  of  the  canal  may  be  distinguished  (Plummer) . 
Figs.  69  and  70  illustrate  the  use  of  a  sound  in  demonstrating  the 
existence  of  a  pocket.  The  sound  is  first  introduced  into  the 
diverticulum  until  obstruction  is  encountered;  holding  the  sound 
in  place,  the  thread  is  drawn  taut.  Traction  on  the  thread  will 
now  lift  the  sound  out  of  the  diverticulum  sufficiently  far  to  bring 
the  point  to  a  level  with  the  opening  into  the  esophagus.  With 
the  silk  thread  as  a  guide,  greater  force  can  be  used  than  would 
otherwise  be  safe  in  dilating  a  stricture  of  the  esophagus. 

Solid  sounds  are  useful,  and  those  principally  in  use  are  of 
English  make,  measuring  about  60  to  80  centimeters  in  length. 
They  are  made  of  tissue  impregnated  with  resin,  wax  and  lacquer; 
are  flexible;  have  a  perfectly  smooth  surface  and  either  a  cylin- 
dric  body  rounded  at  the  point  or  a  conical  shape  tapering  at 
the   point.     These    sounds    are   manufactured   in   all    diameters. 


THE  AT  UKXT  OF  ESOPHAGEAL  STRICTURE 


:;c,:, 


Before  use,  they  arc  immersed  in  warm  water  or  rubbed  with  a 
cloth,  to  render  them  more  flexible.  The  correct  degree  of  hard- 
ness is  attained  when  the  horizontally  held  instrument  bends 
downward  by  its  own  weight.  Recently  sounds  have  been  manu- 
factured of  duret.  By  a  special  method  of  treatment,  great  resist- 
ance is  imparted  to  this  rubber,  which  may  also  be  boiled  without 
injury. 

Hollow  sounds,  as  well  as  solid  ones,  are  in  use.  They  are  made 
of  tissue  covered  with  resin,  wax  and  lacquer,  and  are  provided 
with  one  or  two  openings  at  the  lower  end.  The  object  is  to  com- 
bine the  sound  examination  with  simultaneous  artificial  feeding. 


Fig.    69. — Olive-pointed  sound  and 
thread  in  diverticulum. 


Fig.    70. — Olive-pointed   sound   and 
thread  guided  into  esophagus. 


For  this  purpose  the  instrument  is  enlarged  at  the  upper  end  to 
hold  a  perforated  wooden  cone,  which  communicates  through  a 
tube  with  a  funnel  or  irrigator  into  which  nourishing  liquids  may 
be  poured.  Instead  of  making  use  of  a  wooden  cone,  the  funnel 
or  irrigator  may  be  connected  with  a  wide  rubber  tube  that  can 
be  pulled  over  the  end  of  the  sound. 

Technic  of  Introducing  the  Sound. — The  patient  is  informed  of 
what  is  about  to  be  done,  that  the  procedure  is  painless,  and  that 
he  may  continue  breathing  regularly.  This  is  important  in  order 
to  prevent  nervous  retching  and  vomiting.  The  patient  sits 
comfortably  upon  a  chair,  leaning  back  for  support,  with  his  head 
erect  or  bent  very  slightly  backward.    A  rubber  cloth  or  towel 


366  DISEASES  OF  THE  ESOPHAGUS 

is  fastened  at  his  neck,  and  he  is  instructed  to  hold  a  basin  with 
both  hands.  He  is  also  told  not  to  swallow  any  sputum  or  ascend- 
ing food  remnants,  but  to  empty  them  into  the  basin.  Artificial 
teeth  are  removed  before  the  procedure  begins.  The  sound, 
having  been  immersed  in  warm  water  or  lubricated  with  oil  or 
glycerin,  is  held  by  the  operator  with  his  right  hand,  like  a  pen- 
holder. The  first  and  second  fingers  of  the  left  hand  are  inserted 
into  the  patient's  mouth  up  to  the  posterior  faucial  wall,  and  the 
sound  is  introduced  along  the  right  side  of  the  first  finger  or 
between  the  two  fingers  up  to  the  faucial  wall.  At  this  point  the 
cricoid  cartilage,  as  a  posterior  eminence,  offers  resistance.  To 
overcome  this  obstacle  the  patient  is  instructed  to  swallow  several 
times,  or  the  tongue  is  energetically  depressed  forward  and  down- 
ward from  behind  by  means  of  the  first  or  the  first  and  second 
fingers  of  the  left  hand.  This  also  serves  to  push  the  epiglottis 
forward,  so  that  the  cricoid  cartilage  is  moved  away  from  the  verte- 
bral column.  The  sound  is  now  at  liberty  to  enter  the  esophagus, 
where  it  glides  down  almost  by  itself.  It  may  happen,  however, 
that  the  sound  slips  into  one  of  the  pyriform  sinuses,  in  which 
case  it  will  refuse  to  go  down  in  spite  of  all  coaxing.  It  would  be 
wrong  to  use  force,  the  better  plan  being  to  withdraw  the  instru- 
ment and  commence  afresh.  It  may  also  happen  that  the  sound 
finds  its  way  into  the  larynx,  an  accident  which  is  usually  accom- 
panied by  considerable  coughing  and  dyspnea,  thus  clearing  up  the 
situation  immediately.  The  sound  should  then  be  withdrawn, 
and  reintroduced  after  the  patient  has  calmed  himself.  As  soon 
as  the  sound  lies  correctly  in  the  esophagus,  so-called  sound-breath- 
ing may  be  observed,  which  consists  in  a  light  motion  of  air  through 
the  sound,  caused  by  the  pressure  vacillations  within  the  thorax. 

After  the  sound  has  passed  through  the  esophageal  entrance, 
slight  pushing  will  cause  it  to  glide  down,  passing  the  cardia  with- 
out resistance,  and  it  will  be  arrested  only  by  the  greater  curvature. 
It  is  important  to  assure  one's  self  that  the  upper  incisors  do  not 
create  any  friction  with  the  sound,  as  this  would  give  the  erroneous 
sensation  of  resistance  in  the  esophagus. 

If  in  this  way  the  thickest  sound  or  the  stomach  tube  glides 
into  the  stomach  without  resistance,  there  can  be  no  question  of 
any  obstacle  in  the  esophagus.  Should  any  obstacle  be  encoun- 
tered, the  operator,  detecting  its  presence  by  the  guiding  hand, 
must  determine  its  location.  This  is  done  by  marking  the  sound 
in  situ  at  the  point  where  the  incisors  touch  it,  and,  upon  with- 
drawal, measuring  the  distance  from  this  point  to  the  end  of  the 
sound.     (See  schedule  of  distances,  page  349.) 

The  location  of  the  obstacle  being  determined,  the  question 
arises,  how  to  enter  the  stricture  for  the  purpose  of  overcoming  it. 
The  simplest  way  is  to  proceed  gradually  to  the  use  of  thinner  and 
thinner  sounds  until  one  is  found  which  will  pass.     The  sensation 


TREATMENT  OF  ESOPHAGEAL  STRICTURE  367 

of  the  sound  passing  through  is  experienced  by  the  operator's 
guiding  hand.  It  is  frequently  possible  to  feel  the  approximate 
length  of  the  stricture.  There  is  often  a  sensation  as  if  the  sound 
were  passing  through  a  spiral  canal,  and  this  is  found  in  many 
cases  to  be  true. 

The  stricture  may  be  so  narrow  that  even  the  thinnest  sound 
will  not  pass,  or  the  opening  may  be  so  situated  that  the  straight 
sound  cannot  find  it.  In  such  a  case  the  use  of  force,  if  the  sten- 
osis is  carcinomatous,  may  result  in  perforation;  in  cicatricial 
stricture  a  little  additional  pressure  may  be  employed,  but  even 
then  caution  is  necessary.  It  may  happen  that  the  sound  passes 
freely  one  day  but  not  on  the  following  day;  this  is  probably  due 
to  the  irritation  caused  by  the  procedure,  especially  in  carcinoma- 
tous stenosis,  where  an  inflammation  caused  by  the  sound  may  still 
further  constrict  the  lumen.  It  may  then  be  opportune  to  leave 
the  stricture  undisturbed  for  a  few  days,  resorting  to  rectal  feeding 
if  necessary.  If,  after  the  inflammatory  manifestations  have  sub- 
sided, the  sound  cannot  be  introduced,  a  little  artifice  may  help. 
By  bending  the  lower  end  of  the  sound  slightly,  and,  when  inserted, 
gently  rotating  it,  carefully  withdrawing  and  reinserting,  it  is 
often  possible  to  find  a  passage  through  an  eccentrically  situated 


Fig.  71. — Esophageal  sound.     (Crawcour.) 

stricture.  It  may  also  be  desirable  to  change  the  cylindric  sound 
for  a  conical  one.  Several  thin,  well-lubricated  sounds  may  be 
introduced  simultaneously  in  the  hope  of  passing  the  stricture 
by  advancing  the  various  sounds  alternately.  When  an  ordinary 
English  sound  fails,  entrance  to  the  stricture  may  sometimes  be 
effected  with  Crawcour's  sound  (Fig.  71).  This  is  a  straight 
button  sound,  made  of  steel,  rigid  at  the  top  with  a  solid  handle, 
but  flexible  in  the  lower  section,  which  is  a  spiral  of  rolled  plate 
metal.  It  is  made  in  diameters  of  6  to  10  millimeters.  Sometimes 
these  sounds  pass  the  stricture  without  pressure,  owing  to  their 
flexibility  and  weight.  They  can  easily  be  kept  clean  and  are 
then  of  great  durability.  They  are  cleansed  with  water  or  anti- 
septic fluid,  such  as  lysol,  and  dried  warm.  Before  use  they  are 
best  moistened  with  water.  Should  even  the  use  of  this  sound 
prove  unsuccessful,  the  entrance  to  the  stricture  may  perhaps  be 
found  by  the  esophagoscope,  and  the  sound  introduced  under  the 
direct  guidance  of  the  eye.  For  this  purpose  the  ordinary  English 
sounds  are  available.  If  these  should  fail,  the  thread  and  bougie 
should  be  used  as  described  on  page  369. 

Should  none  of  these  methods  be  successful,  no  further  attempts 
should  be  made  at  the  time.     If  the  patient  cannot  be  fed  by  mouth, 


368  DISEASES  OF  THE  ESOPHAGUS 

nutritive  enema ta  should  be  given;  he  should  rest  in  bed  and 
the  sensation  of  hunger  and  thirst  should  be  relieved  by  regular 
rinsing  of  the  mouth  with  ice-water.  Small  doses  of  cocain,  0.01 
to  0.02  Gm.  (|  to  |  grain),  twice  or  three  times  daily,  or  small 
doses  of  morphin,  may  be  administered.  In  this  way  it  may 
happen  that  a  previously  impassable  stricture  becomes  permeable. 
If  not,  and  the  patient  continues  to  lose  in  weight,  we  must  regard 
the  case  as  one  of  practically  impermeable  stricture  and  recom- 
mend gastrostomy.  On  the  other  hand,  it  may  be  possible  for 
the  patient  to  swallow  liquid  food  although  a  sound  cannot  be 
passed.  Generally  speaking,  operation  in  these  cases  of  carcino- 
matous stenosis  should  be  deferred  as  long  as  possible,  provided  the 
emaciation  is  not  extreme.  The  benefit  to  be  derived  from  gastros- 
tomy is,  of  course,  not  very  great,  life  being  prolonged,  on  the 
average,  about  five  months.  In  cicatricial  strictures,  however, 
the  operation  should  on  no  account  be  delayed  until  the  patient 
has  arrived  at  the  last  ebb  of  his  strength,  because  after  gastrostomy 
and  the  improvement  of  nutrition  there  is  still  a  possibility  of 
relieving  the  stricture  either  from  above  or  through  the  stomach. 
In  very  debilitated  carcinomatous  patients  it  is  preferable  to 
provide  an  intestinal  fistula  by  jejunostomy. 

Dilating  the  Stricture. — The  stricture  being  permeated  by  one 
of  the  sounds,  the  next  task  is  to  dilate  it.  This  is  of  particular 
importance  in  cicatricial  strictures,  but  should  also  be  attempted 
in  the  carcinomatous  form.  When  the  location  of  the  stricture 
is  simple,  the  largest  passing  sound  is  allowed  to  remain  in  situ 
for  some  time,  if  possible  for  fifteen  to  thirty  minutes,  the  patient 
being  instructed  to  breathe  quietly  and  to  empty  sputum  and 
mucus  into  a  basin.  Unless  the  patient  is  excited  or  overstrained, 
the  next  larger  sound  may  then  be  introduced  and  allowed  to 
remain  for  some  time;  otherwise  the  procedure  is  deferred  until  the 
next  day.  The  sound  which  has  already  passed  is  then  introduced 
first,  and  upon  withdrawal  is  followed  immediately  by  the  next 
higher  number.  According  to  how  the  patient  bears  the  procedure, 
the  applications  may  be  made  daily  or  every  second  day.  In  this 
way  the  size  of  the  sound  is  constantly  increased,  be  it  the  cylindric, 
conical  or  Crawcour  variety.  Great  caution  is  always  necessary  in 
carcinomatous  stenosis,  while  in  cicatricial  strictures  more  force 
may  be  applied,  the  largest  sound  being  used  in  the  course  of  time. 
In  that  case  lubrication  of  the  sound  is  preferable  to  moistening 
with  water.  Permanent  good  results  have  often  been  attained  in 
cicatricial  strictures  by  this  progressive  dilatation.  Should  the 
scar  contract  again,  as  it  may,  the  treatment  may  have  to  be 
repeated.  In  esophageal  carcinoma  it  would  not  be  correct  to 
force  the  sound  treatment,  especially  when  the  passing  of  the 
instrument  encounters  difficulties.  The  injury  to  which  the  patient 
would  be  thus  exposed  is  greater  than  the  benefit  from  moderate 


TREATMENT  OF  ESOPHAGEAL  STRICTURE  369 

dilatation,  and   there  is  always  the  danger  of  hemorrhage  and 

perforation  to  be  reckoned  with. 
A>  soon  as  the  stricture  lias  been  dilated  to  admit  medium-sized 

sounds,  the  question  of  usini^  hollow  sounds  and  feeding  artificially 
thereby  has  to  be  considered.  In  cases  in  which  the  very  finesl 
English  sound  cannot  pass  through,  it  may  still  be  possible  to  effect 
a  slight  dilatation  by  introducing  well-rounded,  defibrinated  gut 
strings,  which  would  swell  in  the  stricture.  As  these  strings  may 
be  allowed  to  remain  for  several  hours,  the  result  may  be  at  least 
a  dilatation  sufficient  to  admit  the  finest  solid  sound.  The  strings 
may  be  introduced  through  the  esophagoscope  under  the  guidance 
of  the  eye,  several  fine  and  coarser  ones  being  pushed  through  in 
the  hope  that  one  or  more  of  them  may  penetrate  the  stricture. 

The  Sippy   Dilator. — B.  W.  Sippy  has  perfected  a  system    of 
gradual  dilatation  of  esophageal  stricture  by  the  use  of  a  series  of 
conical  metal  bulbs  strung  on  a  piano  wire  concentrically — a  small 
bulb  at  the  extreme  end,  held  in  place  by  a  still  smaller  bulb  welded 
to  the  wire,  and  followed  by  three  or  four  others,  each  larger  than  the 
one  preceding  it,  and  all  pointed  toward  the  end;  then  an  equal 
number  of  bulbs  pointing  in  the  other  direction  and  gradually 
decreasing  in  size,  so  that  the  appearance  is  that  of  a  string  of 
beads,  the  largest  in  the  center.    The  piano  wire  is  four  feet  long, 
Xo.  20,  reduced  in  size  for  greater  flexibility  for  a  distance  of  eight 
inches  from  the  end.    Before  the  conical  bulbs  are  strung  upon  it, 
the  permeability  of  the  stricture  is  determined  as  follows:    The  silk 
thread,  introduced  and  anchored  in  the  manner  described  on  page 
364,  is  threaded  through  the  small  metal  bulb  at  the  end  of  the  piano 
wire,  so  that  the  thread,  held  taut,  serves  as  a  guide  for  the  wire  and 
its  terminal  bulb,  as  well  as  for  the  conical  bulbs  that  are  to  be  later 
strung  upon  it.    The  sounding  is  begun  with  one  of   the  small 
dilators,  or  conical  bulbs,  which  is  held  snugly  against  the  terminal 
bulb  by  a  spiral  "introducer"  twenty  inches  in  length  that  is  slipped 
on  the  wire  from  the  free  end.  If  the  dilator  passes  down  the  esopha- 
gus freely,  a  larger  size  is  chosen,  and  so  on  until  a  snug  fit  is  found. 
This  is  removed  and  the  wire  is  strung  with  the  graded  series  of  dila- 
tors or  conical  bulbs  as  already  described,  the  largest  being  just  a 
trifle  larger  than  the  bulb  which  has  been  found  to  fit  the  stricture. 
The  spiral  introducer,  with  a  bulb  attached  that  is  a  little  smaller 
than  the  upper  terminal  bulb  on  the  wire,  is  then  slipped  on  the  wire 
and  pressed  against  the  row  of  strung  bulbs;  the  latter  passes  gradu- 
ally down  the  esophagus  until  the  central  dilators  have  passed  the 
stricture.    The  stricture,  having  been  thus  dilated  from  above,  is 
dilated  from  below  as  the  bulbs  are  drawn  upward  by  traction  on 
the  free  end  of  the  wire.    The  pressure  is  almost  entirely  lateral, 
owing  to  the  conical  form  of  the  dilating  bulbs;  and  the  flexibility 
of  the  whole  apparatus,  which  is  nevertheless  held  securely  in  the 
esophageal  channel,  is  a  most  commendable  feature.    Sippy  says 
24 


370 


DISEASES  OF  THE  ESOPHAGUS 


that  by  this  method  the  most  tortuous  stricture  may  be  dilated  with 
the  minimum  degree  of  traumatism.  While  dilatation  is  proceeding, 
the  silk  thread  by  which  the  wire  and  its  load  are  guided  is  held  by 
an  assistant,  for  the  operator  requires  both  hands  to  conduct  the 


Fig.  72. — Esophageal  dilator.     (Sippy.) 

advance  and  return  of  the  dilators — one  for  the  wire  and  the  other 
for  the  introducer.    The  Sippy  apparatus  is  shown  in  Fig.  72. 

Senator  devised  a  dilating  instrument  consisting  of  a  soft  French 
sound  provided  with  a  metal  end,  to  which  a  thin  laminaria  tent 


Fig.  73. — Esophageal  dilator.     (Senator.) 

of  varying  thicknesses  can  be  connected  by  means  of  a  screw. 
The  tent  is  also  secured  by  two  silk  threads  (Fig.  73) .  The  sound 
is  introduced  far  enough  to  allow  the  tent  to  lie  in  the  stricture. 
This  may  be  done  in  the  esophagoscope  under  guidance  of  the 


CM 


1L 


SHjz^ 


5»€ 


An.  £ 


&         Sp. 

■--"-.-■-■-£-»C^> 


Fig.  74. — Esophageal  dilator.     (Schreiber.) 


eye,  the  tent  being  first  moistened  with  water  so  that  it  will  swell 
when  placed  in  position.  The  sound  is  then  detached  (unscrewed), 
and  thetent,  with  its  silk  threads  hanging  out  of  the  patient's 
mouth,  is  allowed  to  remain  for  several  horns.    The  tent  should 


TREATMENT  OF  ESOPHAGEAL  STRICTURE 


371 


not  remain  in  the  stricture  long  enough  to  render  its  withdrawal 
difficult  on  account  of  increase  in  volume.  When  withdrawn  it 
should  be  cleansed  with  water  and  dried,  after  which  it  can  be 
used  again.  Some  authors  have  achieved  good  results  with  this 
treatment. 

Another  means  for  energetically  dilating  a  permeable  stricture 
is  the  dilating  sound  of  Schreiber  (Fig.  74).  This  instrument  is  a 
metal  sound  with  a  small  rubber  balloon  attachment.  A  thin 
whalebone,  introduced  into  this  sound  from  its  lower  end,  can  be 
screwed  to  the  metal  lengthening  piece  at  k;  it  carries  a  conical 
end-piece  (Sp)  and  the  rubber  balloon  (d.g.).  The  upper  and  lower 
ends  of  this  rubber  balloon  are  fastened  with  silk  threads.  A  syringe 
holding  about  10  Cc.  of  water  is  provided  with  a  conical  mouth-piece 
which  fits  exactly  into  e.  To  remove  the  air  in  the  sound,  the  piston 
of  the  syringe  is  withdrawn  once  or  twice,  the  sound  being  held  in 
an  upright  position.  The  syringe  being  removed,  the  little  water 
contained  in  the  rubber  balloon  is  squeezed  out  by  compression. 


Fig.  75.- — Esophageal  bougie  and  cannula.     (Leyden  and  Renvers.) 

The  cock  is  now  closed  and  the  sound  introduced.  In  a  normal 
esophagus  the  sound  glides  smoothly  into  the  stomach.  If  now 
about  10  Cc.  of  water  be  injected  into  the  rubber  balloon,  it  fills 
out  to  a  circumference  of  7  to  9  centimeters,  not  too  large  to  prevent 
it  from  passing  a  normal  cardia  upon  withdrawal  of  the  sound, 
but  it  is  always  arrested  by  the  cricoid  cartilage  at  the  esophageal 
entrance,  so  that  the  cock  has  to  be  opened  to  permit  of  its  with- 
drawal. If  there  is  a  stricture  in  the  esophagus,  the  balloon  is 
arrested  sooner,  so  that  the  instrument  is  to  a  certain  extent  of 
diagnostic  service.  Besides,  the  balloon  can  be  used  for  dilating 
the  stricture,  being  either  drawn,  filled  with  water,  into  the  stricture 
from  below  and  allowed  to  remain  there,  or  introduced  empty  by 
means  of  the  sound  into  the  stricture  (provided  the  location  of  the 
latter  is  known)  and  then  distended  with  water.  With  this  instru- 
ment it  is  possible  to  exert  uniform  pressure,  without  any  danger  of 
injury. 

Sounds  for  esophageal  strictures  have  also  been  devised  by 
Leyden  and  Renvers,  with  the  object  of  inserting  a  cannula  after 
the  manner  of  laryngeal  intubations,  to  keep  the  esophageal  stric- 


372  DISEASES  OF  THE  ESOPHAGUS 

ture  permeable  and  render  the  introduction  of  sufficient  food 
possible.  These  permanent  cannulse  (Fig.  75)  are  5.  to  10  centi- 
meters long,  with  an  upper  lumen  of  12  to  14  millimeters  and  a 
lower  of  5  to  6;  but  they  are  manufactured  in  different  sizes.  The 
upper  end  of  the  cannula  is  not  round,  but  flattened  from  front  to 
back,  so  that  the  cannula  may  pass  the  cricoid  cartilage  more  easily 
as  it  is  withdrawn.  At  both  sides  of  the  upper  end  of  the  cannula 
there  are  apertures  for  coarse  silk  threads  which  are  fastened  to 
the  sound  by  a  clamp  at  the  time  of  insertion.  The  sound  itself 
is  a  bougie  with  a  handle,  and  is  equipped  with  two  ivory  buttons, 
the  lower  of  which  serves  as  obturator  for  the  lower  aperture  of 
the  cannula,  while  the  other  secures  the  upper  end  of  that  instru- 
ment. Intelligent  use  of  the  cannula  presupposes,  of  course,  an 
approximate  knowledge  of  the  location  and  length  of  the  stricture. 
Any  food  remnants  or  mucus  that  may  be  in  the  esophagus  must 
be  removed  by  irrigation,  before  the  sound  is  inserted.  The  use 
of  this  cannula  is  perhaps  most  suitable  in  cases  of  carcinomatous 
stricture  which  do  not  ulcerate  and  are  not  yet  too  far  advanced. 
Extreme  care  is  imperative,  because  a  certain  amount  of  force 
has  to  be  employed.  It  goes  without  saying  that  lesions  must 
be  rigidly  avoided.  As  soon  as  the  cannula  lies  firmly  in  the 
stricture,  the  silk  threads  are  detached  from  the  clamp  and  the 
sound  loosened  and  withdrawn  by  rotary  and  lateral  movements. 
The  free  ends  of  the  threads  are  conducted  out  at  the  angles  of  the 
mouth  and  securely  fastened  behind  the  ears. 

Surgical  Treatment. — Aside  from  the  treatment  by  dilatation,  in 
cases  of  carcinoma  of  the  esophagus  surgical  intervention  must  be 
considered.  Czerny  was  the  first  to  carry  out  resection  in  the  cervical 
section  of  the  esophagus,  in  1877.  with  favorable  results.  Since 
then  the  operation  has  been  repeated  about  twenty-five  times, 
unfortunately  with  but  a  small  measure  of  success.  The  immediate 
operative  mortality  is  at  least  36  per  cent.  The  final  results  are 
likewise  bad,  because  in  most  cases  recrudescence  occurs  sooner 
or  later.  Operative  cases  must  be  very  critically  selected.  All 
the  neighboring  organs  which  are  involved  must  be  removed,  as 
far  as  possible,  and  the  esophageal  operation  must  be  preceded 
by  gastrostomy.  Carcinomata ,  in  the  thoracic  section  of  the 
esophagus  may  be  attacked  with  the  aid  of  intracheal  insufflation 
of  ether  (Meltzer  and  Auer),  but  the  results  so  far  have  been  bad. 
Carcinoma  of  the  cardia,  however,  where  the  lowest  part  of  the 
esophagus  can  be  connected  with  the  stomach  after  resection  of  the 
carcinoma,  offers  a  more  favorable  proposition. 

Alimentation. — In  all  cases  alimentation  by  mouth  should  be 
maintained  as  long  as  possible.  The  diet  should  be  soft,  liquid  or 
pulpy,  according  to  the  narrowness  of  the  stricture.  Since  the 
stomach  is  usually  healthy,  it  does  not  matter  so  much  what  kind 
of  food  is  administered,  but  rather  that  the  food  be  given  in  a 


TREATMENT  OF  ESOPHAGEAL  STRICTURE  373 

form  which  facilitates  deglutition.  As  the  stricture  increases,  the 
problem  of  nutrition  becomes  more  difficult.  It  is,  of  course, 
absolutely  necessary  that  the  food  be  not  excessively  spiced  or 
acid,  in  order  to  prevent  irritation  of  the  carcinomatous  tissue. 
Swallowing  a  tablespoonful  of  olive  oil  or  sweet  almond  oil,  or  the 
yolk  of  an  egg,  previous  to  the  ingestion  of  food,  for  its  lubricating 
effect  upon  the  stricture,  is  to  be  recommended.  When  it  becomes 
necessary  to  abandon  mouth  feeding  entirely,  the  patient's  spirits 
and  to  some  extent  his  strength  may  be  sustained  by  nutritive 
enemata  (see  page  243). 

Should  food  remnants,  mucus,  blood  and  pus  accumulate  above 
the  stricture,  the  esophagus  should  be  frequently  irrigated  by  means 
of  a  soft-rubber  stomach  tube  or  hollow  sound,  using  either  warm 
water,  salicylic  acid  (1:1000),  silver  nitrate  (1:1000)  or  thymol 
(1:2000)  solution.  Even  when  there  is  no  accumulation  of  food 
remnants,  it  is  well  to  let  the  patient  drink  small  quantities  of 
alkaline  mineral  water  both  morning  and  evening. 

Aside  from  these  measures,  the  treatment  of  carcinoma  of  the 
esophagus  can  only  be  ameliorative,  in  the  endeavor  to  relieve 
the  symptoms  as  far  as  possible.  For  this  purpose  morphin  is 
administered  subcutaneously  and  internally,  eucain  or  cocain 
solution  injected  with  the  esophageal  syringe  (Fig.  68),  or  tablets 
of  cocain  0.02  Gm.  (-|  grain),  anesthesin  or  orthoform  swallowed. 
The  following  prescription  is  often  useful : 

Gm.  or  Cc. 

]$ — Morphinse  sulphatis, 

Cocainse  hydrochloridi        .      .   aa       01 0025  gr.  ^ 

Antipyrini 0 1 01  gr.  £ 

Saccharini 0  [  3  gr.  v 

Misce  et  ft.  tab.  no.  i. 

Sig. — One  tablet  several  times  daily. 

In  the  presence  of  pains  and  spasms,  atropin  may  be  adminis- 
tered to  advantage,  both  subcutaneously  and  by  mouth.  In  order 
to  restrict  ulceration,  excoriation,  and  secretion  of  mucus,  the 
mineral  waters  may  be  prescribed,  or  solutions  of  bicarbonate  of 
sodium,  hydrogen  peroxid  (1  to  2  per  cent.,  one  teaspoonful  every 
hour),  silver  nitrate  (1  per  cent.),  or  epinephrin  (5  to  10  drops  of 
the  1 :  1000  solution  in  a  teaspoonful  of  water) . 

Cauterization  of  very  prominent  parts  of  the  tumor  is  permis- 
sible under  certain  circumstances,  but  of  course  is  not  attended 
with  permanent  results.  Radium  and  mesothorium  emanations, 
and  the  Roentgen  ray,  may  be  tried  (page  550),  although  permanent 
results  from  this  treatment  have  not  so  far  been  reported. 

As  to  the  treatment  of  cicatricial  stricture,  it  may  again  be 
repeated  that  the  sound  can  and  should  be  used  much  more  ener- 
getically and  persistently  than  in  the  carcinomatous  form,  very 
good  results  having  been  thus  obtained.  Carefully  selected,  non- 
irritating,   concentrated  diet   is    an    essential    item.    Dilatations 


374  DISEASES  OF  THE  ESOPHAGUS 

above  a  cicatricial  stenosis  should  be  irrigated  when  they  contain 
stagnant  food  remnants.  Manifestations  of  irritation  in  the  stric- 
ture should  be  prevented  by  diet,  mineral  waters,  and  liberal  doses 
of  oil.  When  the  stricture  is  very  narrow,  gastrostomy  can  be 
performed  earlier  than  in  carcinoma,  owing  to  the  possibility  of 
continuing  the  sound  treatment  and  dilating  a  deep-seated  stricture 
from  the  stomach. 

DIVERTICULA. 

Traction  Diverticula. — Traction  diverticula  of  the  esophagus  are 
funnel-shaped  or  sac-like  eversions  resulting  from  traction  from 
without.  Inflammatory  processes  in  the  neighborhood  of  the  esoph- 
agus, and  especially  caseous  bronchial  and  tracheal  glands  which 
are  adherent  to  it  and  undergo  cicatricial  shrinking,  pull  upon  the 
esophageal  wall,  everting  it  to  a  certain  extent.  Fibrosis  of  the 
lympE  nodes  situated  opposite  the  level  of  the  bifurcation  of 
the  trachea  exerts  traction  upon  the  wall  of  the  esophagus,  form- 
ing minute  pouches.  These  diverticula  may  be  1  to  1.5  centi- 
meters deep,  and  7  to  8  millimeters  wide  at  the  entrance;  the  inner 
wall  is  smooth,  and  the  mucous  membrane  usually  normal,  though 
in  the  deep  parts  it  is  sometimes  cicatricially  contracted,  blackish 
or  ulcerated.  Traction  diverticula,  as  a  rule,  run  a  course  without 
symptoms,  but  when  inflammatory  processes  occur  in  the  neighbor- 
hood they  may  perforate  and  cause  grave  or  even  fatal  complica- 
tions by  infection  of  the  mediastinum.  Should  dysphagia  occur, 
the  diagnosis  can  be  made  with  the  esophagoscope  and  the  Roent- 
gen ray  (see  Chapter  V) . 

Treatment. — Should  there  be  no  symptoms,  treatment  of  traction 
diverticula  is  usually  unnecessary;  all  that  is  required  is  care  in 
diet,  the  patient  being  provided  with  well  minced  food  of  a  bland 
nature.    Sounds  should  not  be  used. 

Pulsion  Diverticula. — Pulsion  diverticula  may  be  caused  by  pres- 
sure from  within  the  lumen  of  the  esophagus.  Among  etiologic 
factors  are:  impaction  and  pressure  of  foreign  bodies  and  solid 
morsels  in  the  larynx,  hasty  swallowing  of  food,  and  ingestion  of  very 
hot  food.  It  may  be  assumed,  however,  that  these  factors  alone 
are  not  sufficient  to  cause  an  eversion  of  the  esophageal  wall  in  the 
absence  of  any  congenital  or  perhaps  even  continuous  trauma.  In 
this  connection  fetal  development  is  of  importance,  as  many  obser- 
vations point  to  the  possibility  of  these  diverticula  having  developed 
from  remnants  of  the  internal  fetal  sulcus.  They  are  situated  ex- 
clusively at  a  point  in  the  esophagus  beginning  behind  the  pharynx, 
opposite  the  cricoid  cartilage,  at  the  posterior  wall,  more  often  on 
the  right  than  on  the  left  side.  This  is  the  point  where  the  external 
longitudinal  muscular  layer  of  the  esophagus  is  least  developed. 
The  affection  develops  very  slowly;  probably  it  is  often  many  years 
after  initiation  of  the  process  before  there  are  any  symptoms. 


DIVERTICULA  375 

The  size  of  the  diverticula  varies;  some  are  no  larger  than  a  hazel- 
nut; others  measure  13  centimeters  in  length  by  5  centimeters  in 
transverse  diameter.  These  large  diverticula  hang  between  the 
esophagus  and  the  vertebral  column,  with  more  or  less  extensive 
inosculation.  The  majority  of  the  patients  are  between  fifty  and 
sixty  years  of  age. 

Symptoms. — The  symptoms  develop  as  slowly  as  the  affection 
itself,  commencing  with  slight  difficulty  in  swallowing  and  a  slight 
pressure  sensation  in  eating.  Frequently  there  is  also  eructation 
after  meals  and  vomiting  of  small  quantities  of  the  ingested  food. 
As  the  diverticula  increase  in  size,  the  symptoms  become  more 
pronounced.  The  food  glides  into  the  diverticulum,  which,  accord- 
ing to  its  fulness,  presses  against  the  lumen  of  the  esophagus, 
interfering  with  the  passage  of  other  food  to  the  stomach.  The 
diverticulum  is  very  rapidly  filled,  causing  the  food  to  accumu- 
late in  the  pharynx,  whence  it  is  brought  up  and  vomited  in  a 
short  time.  Some  patients  are  able  to  press  the  food  down  by 
inclining  the  head  or  applying  digital  pressure  to  the  side  of  the  neck 
where  the  diverticulum  is  situated.  These  manipulations,  however, 
cease  to  avail  with  the  increasing  compression  of  the  esophagus, 
so  that  finally  no  food  will  reach  the  stomach  at  all.  Now  appear 
the  sequela?  of  chronic  starvation:  pronounced  emaciation,  hunger, 
thirst,  and  inanition.  When  the  food  stagnates  in  the  diverticulum 
for  a  considerable  time,  it  decomposes,  ferments  and  putrefies. 

It  is  a  matter  of  diagnostic  importance  that  these  food  rem- 
nants contain  no  hydrochloric  acid,  but  often  lactic  acid  and  fre- 
quently large  quantities  of  long  microorganisms,  as  revealed  by  the 
microscope.    There  is  often  a  strong,  disagreeable  fetor  ex  ore. 

Large  diverticula  often  occasion  swellings  of  the  neck  which 
can  be  reduced  by  pressure. 

Pressure  of  the  diverticula  upon  neighboring  organs,  vessels, 
nerves  (recurrent  laryngeal),  and  trachea,  is  responsible  for  grave 
cardiac  manifestations  and  dyspnea. 

Diagnosis. — The  esophageal  sound  will  always  glide  into  the 
diverticulum  when  the  latter  is  comparatively  well  filled;  when 
empty,  the  sound  may  glide  into  the  esophagus.  This  is  of  diag- 
nostic importance  in  cases  where  the  findings  of  the  sound  vary. 
The  diagnosis  is  aided  by  the  diverticular  sounds  of  Leube  and  of 
Starck.  The  esophagoscope  is  likewise  of  importance  for  purposes 
of  diagnosis,  as  it  enables  the  physician  to  observe  the  opening  of 
the  diverticulum.  The  Roentgen  ray  will  definitely  locate  the 
diverticulum  (Plate  XI,  Figs.  3  and  4). 

Prognosis. — The  usual  course  of  the  affection  is  for  a  time  favor- 
able, inasmuch  as  it  develops  slowly  and  often  extends  over  decades, 
even  in  advanced  stages,  provided  the  patient  conducts  himself 
correctly.  It  is,  however,  always  a  grave  condition,  from  which 
many  patients  die  of  inanition  or  lead  an  agonizing  existence. 


376  DISEASES  OF  THE  ESOPHAGUS 

Treatment. — Fortunately,  modern  surgery  has  materially  improved 
the  formerly  cheerless  chances  of  these  sufferers.  The  best  method 
for  permanently  curing  the  affection  is  extirpation  of  the  divertic- 
ulum. This  operation  has  lost  much  of  its  danger,  and  a  large 
number  of  operated  cases  have  been  reported  as  having  taken  a 
favorable  course. 

Should  operation,  for  whatever  reason,  not  be  resorted  to,  the 
sound  treatment  is  to  be  instituted.  In  some  cases  it  may  be 
possible  to  press  back  the  protruding  entrance  of  the  divertic- 


Fig.  76. — Diverticular  sound.     (Leube.) 

ulum,  causing  it  to  contract.  By  this  means  the  food  will  be  aided 
in  reaching  the  esophagus.  As  it  is  difficult  in  these  cases  to  enter 
the  esophagus  below  the  diverticulum  with  a  straight  sound, 
a  way  out  of  the  difficulty  would  be  to  deflect  the  lower  end  of 
a  soft-rubber  stomach  sound  and  to  manipulate  the  deflected  end. 
This  may  sometimes  result  in  reaching  the  eccentrically  situated 
esophageal  entrance. 

The   so-called   diverticular   sounds   are   constructed  with   this 
object  in  view.    The  one  devised  by  Leube  (Fig.  76)  is  an  ordi- 


Fig.  77. — Diverticular  sound.     (Starck.) 

nary  stomach  tube,  with  a  peculiar  end-piece  of  German  silver 
wire,  flexible  and  hinged.  This  end-piece  is  inserted  into  the  soft- 
rubber  stomach  tube.  By  means  of  a  ring  which  protrudes  from 
the  upper  end  of  the  tube  it  is  possible  to  make  traction  upon  the 
movable  point  of  the  nozzle,  deflecting  it  anteriorly  together  with 
the  lower  end  of  the  tube.  The  entire  instrument  is  inserted 
beyond  the  cricoid  cartilage,  the  point  is  deflected  anteriorly,  and 
the  sound  is  pushed  down  along  the  anterior  wall.  In  this  way  it 
is  often  possible  to  enter  the  esophagus  below  the  diverticulum. 


FOREIGN  BODIES  IN  THE  ESOPHAGUS  371 

Starck's  sound  (  Fig.  77 )  is  a  powerful  steel  spiral  with  a  metal  core. 
At  its  lower  end  there  is  a  thread  upon  which  a  straight  or  bent 
metal  continuation  of  any  size  may  be  screwed.  The  deflected  end 
is  intended  to  facilitate  penetration  into  an  eccentrically  situated 
esophageal  entrance.  Starck  has  also  devised  a  hollow  sound 
upon  which  the  various  metal  continuations  may  he  screwed,  so 
that  in  case  the  attempt  at  penetration  succeeds  the  sound  may 
at  once  be  used  for  artificial  feeding. 

The  esophagoscope  should  be  used  as  often  as  possible  for  the  pur- 
pose of  finding  the  esophageal  entrance,  sounding,  and  subsequent 
artificial  feeding.  The  sound-treatment  will,  of  course,  be  attended 
with  the  greatest  success  when  the  technic  can  be  so  arranged  that 
the  patient  learns  to  insert  a  hollow  sound  himself  and  use  it  for 
alimentation. 

FOREIGN  BODIES  IN  THE  ESOPHAGUS. 

Obstructions  due  to  foreign  bodies  in  the  esophagus  are  of  frequent 
occurrence.  Thus,  a  mere  morsel  of  solid  food  may  be  arrested  in  a 
stricture,  the  existence  of  which  has  possibly  never  been  suspected. 
But  all  kinds  of  objects  may  occasionally  find  their  way  into  the 
esophagus,  such  as  artificial  teeth,  coins,  fragments  of  bone,  chil- 
dren's toys,  etc.  When  such  an  accident  happens,  if  the  object 
swallowed  (or  half-swallowed)  was  round  and  smooth,  morphin 
is  to  be  administered,  and  a  thick  sound  inserted  if  possible.  The 
purpose  is  (1)  to  determine  the  site  of  the  foreign  body,  which  may 
have  passed  into  the  stomach,  though  the  patient  still  has  the  sensa- 
tion of  its  sticking  in  the  throat;  (2)  to  carefully  and  gently  push  the 
foreign  body  into  the  stomach,  so  that  it  may  be  evacuated  in  the 
natural  way,  since  smooth  objects  do  not  cause  any  injury  to  the 
mucous  membrane.  It  should  also  be  remembered  that  small 
objects  may  sometimes  be  recovered  by  means  of  an  energetic 
emetic.  If  a  pointed,  sharp  or  cutting  object  has  lodged  in  the 
esophagus,  morphin  should  be  administered,  but  the  only  admissible 
use  of  the  sound  under  such  circumstances  is  to  establish  by  very 
careful  manipulation  the  point  of  impaction.  Sounding  is  for- 
bidden when  artificial  teeth  have  been  swallowed ;  these  can  in  most 
cases  be  easily  located  by  the  Roentgen  ray  (see  Chapter  V). 

If  the  foreign  body  is  of  such  form  or  substance,  even  though 
it  be  round  and  smooth,  that  it  cannot  be  evacuated  by  way  of 
the  intestine,  it  must  be  extracted.  With  the  aid  of  the  esophago- 
scope an  effort  may  be  made  to  loosen  the  object  and  to  catch  it 
with  suitable  instruments,  forceps,  coin-catchers,  etc.  Should  this 
method  fail,  esophagotomy  must  be  done.  If  the  foreign  body 
were  allowed  to  remain  in  the  esophagus  it  would  cause  decubital 
ulcers,  hemorrhages,  and  perforations.  Pointed  or  hooked  objects 
mav  even  cause  lesions  of  the  mucosa  when  extraction  is  performed 


378  DISEASES  OF  THE  ESOPHAGUS 

under  the  guidance  of  the  eye.  Should  lesions  occur  during  extrac- 
tion, they  can  be  easily  healed  by  touching  them  with  a  10-  to  15- 
per-cent.  solution  of  silver  nitrate  in  the  esophagoscope,  and  giving 
morphin  if  necessary  (Fig.  64). 

Foreign  bodies  which  are  arrested  at  the  esophageal  entrance  are 
comparatively  easy  to  extract.  Occasionally,  at  least  in  children, 
they  can  be  caught  with  a  deeply  ^inserted  finger  or  with  bent 
pharyngeal  forceps. 

OTHER  CAUSES  OF  ESOPHAGEAL  STRICTURE. 

Thrash. — It  has  already  been  mentioned  that  thrush  is  capable 
of  completely  occluding  the  esophagus.  Should  this  cause  consid- 
erable difficulty  in  swallowing,  an  attempt  may  be  made  to  render 
the  esophagus  permeable  with  a  sound.  As  a  local  antiseptic,  borax 
(in  a  3-per-cent.  solution,  one  tablespoonful  every  two  hours)  seems 
to  have  a  favorable  effect. 

Compression  of  the  Esophagus  from  without  can  take  place, 
aside  from  diverticula,  by  aneurysms,  tumors  of  the  mediastinum, 
lungs  or  vertebral  column,  swelling  of  the  mediastinal  and  bronchial 
lymph  glands  in  tuberculosis  or  leukemia,  and  peri-esophageal 
abscesses.  These  may  frequently  be  made  out  by  means  of  the 
Roentgen  ray  (see  Chapter  V). 

Spasm  of  the  Esophagus. — Spasms  of  the  esophagus  and  cardia, 
caused  by  spastic  stenosis,  are  a  very  frequent  and  practically 
important  affection  (see  Cardiospasm,  Chapter  XVII).  Any  such 
spastic  contraction  renders  the  esophagus  impermeable  at  some 
point.  The  spasm  is  of  varying  intensity  and  duration,  and  may 
be  accompanied  by  more  or  less  pain.  The  attacks  recur  at  inter- 
vals, perhaps  for  years,  or  they  may  disappear  as  suddenly  as 
they  appeared.  They  occur  in  hysterical  and  neurasthenic  indi- 
viduals, being  induced  by  emotions  of  all  kinds.  The  esophageal 
spasm  may  be  merely  the  expression  of  an  isolated  hyperesthesia 
of  the  esophageal  mucosa,  or  it  may  be  a  symptom  of  disturbance 
of  the  vegative  nervous  system  (see  page  387).  There  are  also 
reflex  spasms,  caused  by  other  affections  and  particularly  by 
inflammations  of  the  esophagus;  gout  and  arteriosclerosis  seem  to 
favor  their  occurrence.  Esophageal  spasm  occurs  oftener  in  the 
female  than  in  the  male,  especially  at  middle  age  (see  page  137) . 

Symptoms. — Esophageal  spasm  manifests  itself  principally  in 
disturbed  deglutition.  A  swallowed  morsel  is  arrested  in  the 
esophagus,  and  the  patient  experiences  a  sensation  of  contraction 
and  pressure  in  the  chest,  which  is  often  intensely  painful.  The 
paroxysms  do  not  recur  often  at  first,  but  the  cyclic  form  tends  to 
increase  in  frequency,  always,  however,  observing  certain  intervals. 
This  form  often  passes  into  a  chronic  stage  in  which  there  is  dys- 
phagia whenever  food  is  taken.    After  having  persisted  for  years, 


SPASM  OF  THE  ESOPHAGUS  379 

the  spasms  not  infrequently  disappear  without  any  assignable 
cause  or  therapeutic  endeavor.  'The  pathologic  picture  may  there- 
fore be  one  of  considerable  variation — which  is  diagnostic-ally 
important.  Oftentimes  patients  have  less  difficulty  in  swallowing 
solid  food  than  liquid.  In  other  cases  the  spasm  occurs  only  with 
the  first  bite,  after  which  the  ingestion  of  food  proceeds  without 
difficulty.  Concomitant  manifestations,  such  as  pains,  palpitation, 
fear,  dyspnea,  are  often  very  considerable.  The  esophageal  sound 
meets  with  an  obstacle  at  some  point  in  the  esophagus,  which  may 
disappear  after  a  little  while  and  reappear  at  a  lower  point.  The 
spastically  closed  entrance  of  the  stricture  is  distinctly  visible 
through  the  esophagoscope.  The  Roentgen  fluoroscope  charac- 
teristically illustrates  the  arrest  of  the  opaque  bismuth  meal  and  its 
lightning-like  disappearance. 

Treatment. — Provided  the  diagnosis  of  spastic  stenosis  is  estab- 
lished, the  first  question,  of  course,  is  the  etiologic  treatment — 
treatment  of  the  underlying  affection  (neurasthenia,  hysteria).  In 
neurotic  patients  the  psychic  treatment  is  always  of  great  impor- 
tance. If  treatment  of  the  underlying  cause  should  fail,  sounds 
will  have  to  be  used,  preferably  those  of  the  largest  caliber.  One 
single  application  of  the  thickest  sound,  coupled  with  dilatation, 
often  has  a  curative  effect.  In  any  case,  regular  application  of  the 
larger  sounds  should  remove  spasm  in  time.  Very  good  results 
have  often  been  achieved  by  direct  dilatation  of  the  spastic  cardia 
or  of  the  spastic  part  of  the  esophagus  by  means  of  the  balloon 
sounds  devised  by  Sippy  and  that  of  Myer  (see  page  369).  The 
sound  is  introduced  into  the  stomach  or  below  the  esophageal 
stricture,  inflated,  and  withdrawn  through  the  cardiac  or  esophageal 
stricture,  or  it  is  allowed  to  remain  for  some  time  inflated  in  the 
stricture.  Entrance  of  the  thick  sound  into  the  stricture  is  often 
facilitated  by  having  the  patient  swallow.  There  is  no  need  of  force, 
as  the  mere  presence  of  the  sound  above  the  stricture  is  often  suffi- 
cient to  relieve  the  spasm.  When  in  grave  cases  the  question 
of  nutrition  is  involved,  the  use  of  the  hollow  sound  is  advisable 
in  order  to  combine  artificial  feeding  with  the  procedure.  The 
application  of  the  galvanic  current  has  oftentimes  a  very  favorable 
effect.  For  this  purpose  the  galvanic  gastric  sound  is  inserted  into 
the  stricture,  with  the  anode  in  the  esophagus  and  the  cathode  at 
the  nape  of  the  neck,  the  current  being  allowed  to  pass  for  a  fewT 
minutes.  The  combined  stomach  tube  and  electrode  of  Stockton 
(Fig.  30)  has  given  good  results.  Galvanization  from  the  outside 
may  also  be  beneficial;  the  cathode  is  placed  at  the  side  of  the 
larynx  and  the  anode  against  the  nape  of  the  neck.  Closure  of 
the  cathode  will  cause  irritation  of  the  vagus,  under  the  influence 
of  which  regular  deglutition  will  follow.  In  the  presence  of  very 
pronounced  hyperesthsia  it  is  advisable  to  employ  anesthetics  in  the 
form  of  cocain,  eucain,  anesthesin,  or  orthoform  (see  page  270). 


380  DISEASES  OF  THE  ESOPHAGUS 

Benzyl  benzoate  has  recently  been  used  with  benefit  in  cases  of  spasm 
of  the  esophagus  (see  page  276). 

Dilatation  of  the  Esophagus. — Pathologic  dilatations  of  the 
esophagus  are  either  diffuse  (uniform)  or  partial.  The  entire  length 
of  the  esophagus  is  rarely  involved.  The  favorite  seat  is  above 
an  organic  stenosis,  but  this  does  not  signify  that  every  stricture 
is  followed  by  dilatation,  for  the  musculature  of  the  esophagus 
is  strong  enough  to  rapidly  throw  out  food,  mucus  and  sputum 
which  collect  above  even  pronounced  strictures.  It  is  only  when 
the  musculature  weakens  that  a  part  of  the  esophageal  wall  is 
dilated,  less  often  the  entire  section  above  the  stricture.  The 
mucous  membrane  in  the  dilated  area  is  inflamed,  and  the  stagnant 
food  remnants  exert  pressure  upon  it;  frequent  vomiting,  eructa- 
tion, and  offensive  fetor  ex  ore  are  among  the  manifestations. 

A  dilated  condition  of  the  esophagus  without  any  anatomic 
obstacles  is  clinically  and  therapeutically  more  important.  These 
cases  are  now  well  known  clinically.  There  is  usually  a  uniform 
fusiform  dilatation  which  extends  upward  from  the  diaphragm. 
The  esophagus  is  cystically  distended,  the  greatest  diameter  of  the 
sac  being  immediately  above  the  diaphragm.  In  some  cases  the 
distended  part  resembles  an  elongated  ellipsoid.  The  musculature 
in  the  dilated  area,  notably  the  layer  of  circular  fibers,  is  usually 
hypertrophic.  The  mucous  membrane  may  be  normal,  but  usually 
it  is  hypertrophic  and  sometimes  inflamed,  covered  with  papillary 
proliferations,  or  eroded. 

Etiology. — Etiologically,  spasms  of  the  cardia  or  of  the  lower 
section  of  the  esophagus  are  chiefly  to  be  considered.  Further 
etiologic  factors  are  atony  of  the  esophagus,  with  subsequent  dis- 
tention and  secondary  cardiospasm.  Trauma  has  also  been  held 
responsible,  and  it  may  well  be  imagined  that  a  trauma  may  lead 
to  a  spasm,  or  atony  or  paralysis  of  the  esophagus.  Organic 
affections  of  the  central  nervous  system  or  of  the  vagi  may  likewise 
cause  disturbances  in  the  innervation  of  the  cardia  and  esophagus. 
The  affection  occurs  principally  in  neurotic  patients,  and  is  about 
equally  distributed  between  the  two  sexes.  It  occurs  between  the 
ages  of  fifteen  and  forty.  Experience  confirms  the  necessity  for 
examining  for  gastroptosis  in  every  case  of  dilatation  of  the 
esophagus,  as  the  latter  may  be  due  to  kinking  from  sagging  of 
the  stomach. 

Symptoms. — The  symptoms,  especially  in  the  initia  stage,  re- 
semble those  of  spastic  stenosis  described  above.  In  the  pro- 
nounced pathologic  picture  there  is  this  prominent  fact  to  be 
considered,  that  the  food  can  be  swallowed  but  not  conveyed  to 
the  stomach;  the  sensation  is  as  if  the  food  were  arrested  imme- 
diately before  reaching  the  stomach.  For  this  reason  the  manifes- 
tations are  often  referred  in  the  beginning  to  the  stomach  itself, 
the  associated  symptoms,  such  as  pressure  and  pain,  being  localized 


DILATATION  OF  THE  ESOPHAGUS  381 

in  the  region  of  the  epigastric  angle.  According  to  the  development 
of  the  sac,  the  symptoms  vary.  It  is  easy  to  understand  that  a 
large,  well-filled  sac  exerts  great  pressure  upon  the  neighboring 
organs,  the  heart,  diaphragm  and  lungs,  causing  corresponding 
disturbances.  Oftentimes  patients  are  awakened  from  sleep  by 
violent  paroxysms  of  coughing  and  suffocation,  especially  when  in 
the  horizontal  decubitus  the  sac  is  evacuated  upward  and  part 
of  the  evacuated  mass  invades  the  larynx. 

Diagnosis. — All  these  manifestations,  considered  in  conjunction 
with  those  of  cardiospasm  and  esophageal  spasm,  point  to  the 
correct  diagnosis.  The  latter  is  assured  by  examination  with  the 
sound,  which  can  either  not  pass  into  the  stomach  at  all,  or  only 
with  difficulty.  In  this  connection,  the  changing  chemism  of  the 
material  thus  obtained  is  important,  particularly  when  the  sound 
once  in  a  while  happens  to  enter  the  stomach  and  gastric  contents 
can  be  withdrawn.  Aside  from  the  sound,  the  esophagoscope  is 
of  diagnostic  service,  as  the  dilated  esophageal  wall  presents  numer- 
ous folds  and  ridges  of  mucous  membrane.  Furthermore,  Roentgen- 
ray  examination  (see  Chapter  V)  will  serve  to  establish  the  exact 
diagnosis  by  showing  with  the  aid  of  bismuth  the  dilated  area. 
The  condition  of  the  mucous  membrane  is  established  by  the 
esophagoscope. 

Prognosis, — The  prognosis  is  not  so  unfavorable  as  in  diverticula. 
Cases  which  are  not  too  pronounced  or  too  old  can  unquestionably 
be  cured  or  improved.  Even  in  considerable  dilatations  of  the 
esophagus  it  is  possible  in  most  cases  to  maintain  the  state  of 
nutrition  sufficiently  to  prevent  a  fatal  termination. 

Treatment. — The  treatment  depends  upon  whether  spasm,  atony 
or  other  organic  change  (esophagitis)  has  given  rise  to  the  dila- 
tation. When  there  is  spasm  of  the  cardia,  it  is  clear  that  the 
spasm  has  to  be  treated  as  such,  in  the  manner  described  under 
that  head.  It  should  be  added,  however,  that  those  conditions 
of  cardiospasm  which  occur  as  sequelae  to  chronic  inflammatory 
processes  of  the  mucous  membrane  are  not  suitable  for  sound 
treatment.  Such  organic  changes  of  the  mucosa  might  be  exacer- 
bated by  sounding,  thereby  increasing  the  inclination  to  spasm. 
In  this  secondary  spasm,  therapeutic  measures  are  often  very 
successful.  The  patient  is  to  have  physical  and  mental  rest,  and 
if  necessary  be  enjoined  to  keep  long  hours  in  bed.  All  kinds  of 
stimulants  (alcohol,  coffee)  must  be  strictly  avoided.  The  diet 
should  be  absolutely  non-irritating.  Moist  packing  of  the  chest, 
packing  of  the  body,  warm  baths  and  pine  needle  baths  are  often 
beneficial.  In  the  presence  of  highly  irritating  conditions  and 
considerable  anxiety,  regular  small  doses  of  opium  and  bromid 
(tincture  of  opium  0.3  Cc,  potassium  bromid  0.5  to  1  gram)  or 
morphin  should  be  prescribed.  Papaverin  and  benzyl  benzoate 
are  both  valuable  (see  page  276).     Daily  irrigation  of  the  dilated 


382  •  DISEASES  OF  THE  ESOPHAGUS 

esophagus  will  no  doubt  improve  the  condition.  Should  the  spasms 
nevertheless  persist,  local  treatment  of  the  cardia  should  be  insti- 
tuted. After  irrigation  of  the  esophagus,  the  application  of  a  3-  to  4- 
per-cent.  eucain  solution  to  the  cardiac  region  will  serve  to  reduce  the 
irritability  of  the  cardia.  Galvanization  of  the  cardia  also  has  a 
soothing  effect.  This  can  be  carried  out  with  the  ordinary  stomach 
electrode  or  a  tube  electrode  devised  by  Stockton  (Fig.  30).  A 
very  weak  galvanic  current,  0.5  to  1  or  2  milliamperes,  is  applied, 
according  to  the  sensitiveness  of  the  patient. 

When  there  is  a  purely  nervous  spasm  of  the  esophagus  or  cardia, 
the  treatment  described  under  Cardiospasm  is  to  be  applied  to 
relieve  the  stricture.  It  may  be  again  pointed  out  that  dilatation 
of  spastic  stenosis  with  the  balloon  sound,  as  described  on  page  397, 
has  'often  been  attended  with  brilliant  results,  provided,  of  course, 
the  cardia  was  at  all  permeable. 

Among  the  general  measures  which  hold  good  for  all  kinds  of 
fusiform  dilatations  of  the  esophagus,  irrigation  of  the  dilated 
canal  ranks  first.  The  sac  is  irrigated  daily  after  the  manner 
of  gastric  lavage,  preferably  in  the  evening  before  going  to  bed. 
In  order  to  prevent  irritation  of  the  stomach  and  intestine,  it  is 
important  to  see  that  as  little  as  possible  of  the  decomposed  mass 
enters  the  gastro-intestinal  canal.  The  best  plan  is  for  the  patient 
to  acquire  the  technic  of  the  irrigation  himself,  which  is  not  as 
a  rule  a  very  difficult  matter.  Good  olive  oil  and  sweet  almond 
oil,  flowing  into  the  esophagus  after  irrigation,  will  reduce  its 
irritability.  Another  important  point  is  physical  and  mental  rest. 
Patients  whose  condition  is  run  down  from  lack  of  nourishment 
urgently  require  prolonged  rest  in  bed.  The  ingestion  of  plenty 
of  good  food  is  of  great  importance.  During  the  first  two  or  three 
weeks  nourishment  is  best  administered  by  the  sound  in  order  to 
eliminate  deglutition,  but  for  reasons  above  cited  this  is  impos- 
sible in  the  presence  of  inflammatory  changes  in  the  esophagus. 
In  these  cases  rectal  alimentation  in  the  beginning  of  the  treat- 
ment, continued  for  several  days,  would  be  indicated  (see  page  243) . 
The  food  taken  by  mouth  should  be  absolutely  non-irritating,  as 
high  in  calories  as  possible,  and  not  too  abundant.  Generally 
speaking,  soft  and  pappy  foods  should  be  given,  above  all  much 
fat,  cream,  oil  and  butter.  Meat  and  vegetables,  prepared  in  a 
puree  form,  are  of  course  permitted. 

The  atonic  form  of  dilatation  is  often  favorably  influenced  by 
mild  gymnastics,  hydrotherapy,  and  breathing  exercises,  owing 
to  their  effect  upon  the  peristalsis  of  the  esophagus. 

Congenital  Dilatation. — Congenital  dilatation  is  a  partial  dilata- 
tion of  the  esophagus  which  occurs  immediately  above  the  point 
where  the  esophagus  passes  through  the  diaphragm,  involving  but 
a  small  section  of  it.  This  is  the  part  which  Luschka  has  termed 
the  manyplies  ("Vormagen"). 


RUPTURE,  MALAC1A,   PERFORATION,  HEMORRHAGE     383 

Congenital  Stricture.  -Congenital  stricture  may  assume  any  of 
the  following  forms: 

(1)  Simple  blind  termination  of  the  esophagus,  which  is  a  very 
rare  occurrence.  The  existing  part  of  the  organ  is  a  sac,  tapering 
at  the  lower  end  and  resembling  a  diverticulum.  This  cul-de-sac 
may  communicate  with  the  cardia  by  a  thin  cord. 

(2)  Blind  termination  of  the  upper  end  of  the  esophagus.  The 
lower  two-thirds  of  the  developed  esophagus  communicates  with 
the  air  passages,  permitting  the  trachea  to  be  reached  by  the 
sound.  The  two  parts  of  the  esophagus  may  communicate  by  a 
muscular  coat,  or  this  connection  may  be  absent. 

(3)  The  rare  occurrence  of  complete  obliteration  of  the  normally 
permeable  esophagus  at  or  below  the  level  of  the  bifurcation  of  the 
trachea.  Infants  with  this  form  of  congenital  stricture  are  often 
subject  to  other  malformations  and  nearly  always  asthenic.  They 
can  either  not  swallow  at  all,  or  the  milk  returns  through  the  nose. 
The  occlusion  of  the  upper  section  of  the  esophagus  can  be  verified 
with  the  sound.  Usually  these  infants  die  soon.  Operative  inter- 
vention, which  has  been  attempted,  has  proved  futile.  It  might 
be  possible  to  invigorate  these  patients  first  by  the  aid  of  gastros- 
tomy, and  resort  to  operation  later. 

(4)  Membranous  occlusion  of  the  esophagus.  This  consists  of 
a  plicated  membranous  or  annular  fold ;  very  few  locations  on  the 
esophageal  mucosa  are  subject  to  this  deformity,  which,  when  it 
occurs,  jeopardizes  the  permeability  of  the  esophagus.  When  the 
situation  is  favorable,  operative  intervention  may  be  indicated. 

(5)  Simple  strictures  which,  according  to  the  anamnesis,  have 
caused  trouble  from  infancy  and  anatomically  exhibit  a  perfectly 
normal  condition  of  the  esophageal  mucosa  and  musculature,  with- 
out any  cicatrization.  These  strictures  often  do  not  cause  any 
symptoms  until  the  time  comes  when  coarser  food  is  taken.  By 
careful  dieting  it  is  possible  to  preserve  life  for  years,  and  in  these 
cases  sound  treatment  is  distinctly  hopeful. 

Rupture,  Malacia,  Perforation,  Hemorrhage.  —  Rupture  of  a 
perfectly  healthy  esophagus  may  occur  from  grave  thoracic  trauma. 
Spontaneous  rupture  is  exceedingly  rare,  but  may  occur  in  a  per- 
fectly healthy  esophagus  from  sudden  extreme  exaggeration  of  the 
internal  pressure  in  violent  vomiting  or  forcible  contraction  of 
the  esophageal  musculature  caused  by  a  large,  hard  morsel  of  food. 
Esophagomalacia  also  undoubtedly  plays  a  role  in  spontaneous 
rupture.  Esophagomalacia,  like  gastromalacia,  often  occurs  after 
death,  as  a  result  of  the  action  of  the  acid  gastric  juice  upon  the 
dead  membrane;  or  it  may  occur  shortly  before  death,  when,  in 
a  state  of  greatest  debility  or  unconsciousness  (meningitis),  the 
patient  is  unable  to  prevent  regurgitation  of  gastric  contents  into 
the  esophagus.  In  either  case  the  esophageal  mucosa,  not  being 
any  longer  supplied  with  sufficient  blood,  can  become  softened  and 


384  DISEASES  OF  THE  ESOPHAGUS 

digested.  Evidently,  however,  esophagomalacia  may  in  exceedingly 
rare  cases  occur  in  otherwise  healthy  individuals,  when  in  some 
way  or  other  a  possibility  has  been  created  for  the  entrance  of  acid 
gastric  contents  into  the  esophagus.  Predisposing  factors  are 
atony  of  the  cardia  and  esophagus,  habitual  vomiting,  hyperacidity, 
tendency  to  eructation  and  vomiting  after  an  abundant  meal  at  the 
height  of  digestion,  prolonged  shaking  of  the  body  (as  in  horse- 
back or  automobile  riding  after  meals).  Esophagomalacia  nearly 
always  selects  confirmed  smokers  and  drinkers.  As  a  rule  the 
rupture  occurs  immediately  above  the  cardia  in  the  shape  of  a 
longitudinal  tear;  a  circular  tear  has  been  observed  only  once. 

Rupture  is,  of  course,  always  followed  by  the  gravest  conse- 
quences. According  to  the  reported  cases  which  have  been  verified 
at  autopsy,  violent  pain  is  experienced  at  the  place  of  rupture  at 
the  moment  it  takes  place,  rapidly  followed  by  the  gravest  manifes- 
tations— terrifying  fear,  dyspnea,  collapse,  pain,  hematemesis. 
Deglutition  is  usually  not  interfered  with.  Rapid  development  of 
cutaneous  emphysema,  spreading  from  the  face  and  neck  over  the 
entire  body,  is  of  diagnostic  importance.  The  next  manifestations 
are  pneumothorax,  pyothorax,  and  all  the  grave  symptoms  of  an 
infected  mediastinum.  Death  usually  occurs  within  twenty-four 
hours. 

Hemorrhage  in  the  esophagus  may  occur  in  the  course  of  ulcerous 
processes,  carcinoma,  corrosions,  and  in  ruptures.  The  gravest  and 
most  important  esophageal  hemorrhages  are  those  from  the  varices, 
which  are  found  mostly  in  the  lower  third  of  the  esophagus, 
above  the  diaphragm.  The  veins  of  the  esophagus  communicate 
with  the  portal  vein,  and  this  explains  that  stasis  in  the  portal 
circulation  leads  to  formation  of  varices.  These  varices  are  espe- 
cially found  in  cases  of  hepatic  cirrhosis,  syphilitic  affections  of  the 
liver,  thrombosis  of  the  portal  vein  and  the  mesenteric  veins.  But 
they  are  not  always  dependent  upon  portal  stasis.  These  esophageal 
varices  may  attain  to  the  diameter  of  a  lead-pencil.  A  diagnosis 
of  varices  can  hardly  be  made,  because  the  blood  vomited  from  the 
esophagus  may  just  as  well  come  from  the  stomach.  The  hemor- 
rhage is  usually  very  profuse.    (See  page  592.) 

Esophageal  hemorrhage  is  treated  by  means  of  the  ordinary 
styptics  (ice,  injections  of  gelatin  or  ergotin);  absolute  rest;  saline 
hypodermoelysis;  10-per-cent.  sodium  chlorid  solution  intravenously. 
The  administration  of  hemostatic  serum  is  beneficial  if  the  coagu- 
lating power  of  the  blood  is  below  normal  (see  Chapter  XXVI). 

NEUROSES  OF  THE  ESOPHAGUS. 

Hyperesthesia. — Hyperesthesia  of  the  esophageal  mucosa  occurs 
in  hysteria  and  neurasthenia,  in  conjunction  with  spasm  of  the 
esophagus  and  cardia.     It  is  also  a  concomitant  manifestation  of 


NEUROSES  OF  THE  ESOPHAGUS  385 

various  affections  of  the  esophagus  (inflammations,  ulcers,  carci- 
noma) and  is  very  frequently  found  in  gastric  affections  (hyper- 
acidity, hypersecretion).  The  symptoms  of  hyperesthesia  vary 
considerably.  There  are  often  pains  in  swallowing,  together  with 
spasms.  Sometimes  there  are  unpleasant  sensations  in  the  esopha- 
gus when  no  food  has  been  ingested — such  as  burning,  pressure, 
and  spasm,  which  may  disappear  during  a  meal.  The  seat  of 
these  symptoms  may  be  the  entire  esophagus  or  a  few  sections 
of  it.  A  similar  disturbance  is  the  so-called  globus  hystericus,  but 
according  to  present  views  this  sensation  may  also  be  present  with- 
out hysteria.  Pyrosis  also  involves  hyperesthesia  of  the  esophagus, 
as  a  consequence  of  the  gastric  contents  moistening  the  esophageal 
mucosa;  or  the  hyperesthesia  may  be  purely  neurotic  without  any 
regurgitation  of  gastric  contents.  In  order  to  make  a  diagnosis  it 
must  be  established  by  the  sound  whether  there  is  a  free  passage, 
and  this  procedure  may  sometimes  cause  pain.  The  esophagoscope 
will  reveal  any  anatomic  changes.  As  a  rule  the  affection  is  very 
obstinate. 

Treatment. — The  treatment  is  principally  dependent  upon  the 
etiology.  As  to  local  treatment,  a  silver  nitrate  solution  (0.2  to 
0.3  per  cent.),  half  a  tablespoonful  in  a  wineglass  of  distilled  water, 
to  be  slowdy  taken  in  sips  three  times  daily  upon  an  empty  stomach, 
has  been  highly  recommended.  The  application  of  sounds  may  be 
useful.  Rosenheim  recommends  a  soft  stomach  tube  covered  with 
molten  cocain  (0.4  :  10  cacao  butter),  to  be  inserted  and  allowed 
to  remain  for  about  ten  minutes.  Eucain  injections  (4  per  cent.) 
are  also  recommended.  Other  drugs  which  are  sometimes  bene- 
ficial are  bromids,  morphin  and  atropin. 

Anesthesia. — Anesthesia  of  the  esophagus  is  possible,  but  nothing 
definite  is  known  on  this  point. 

Paralysis. — Paralysis  of  the  esophagus  occurs  as  a  part  manifes- 
tation of  central  paralysis  (apoplexy),  bulbar  paralysis,  or  multiple 
sclerosis,  when  the  nuclei  or  trunks  of  the  vagi  become  affected. 
Affections  of  the  vagus  also  occur  in  the  presence  of  mediastinal 
tumors.  A  preceding  diphtheria  may  cause  paralysis  of  the  pharynx 
and  esophagus.  Paralysis  has  also  been  observed  after  grave 
trauma,  and  it  is  just  possible  that  hysteria  likewise  plays  a  role 
in  this  respect. 

Symptoms. — Impeded  deglutition  is  the  principal  symptom,  the 
food  being  arrested  at  some  point  in  the  esophagus,  wdience  it  can 
only  be  forced  into  the  stomach  by  repeated  swallowing  efforts 
or  the  swallowing  of  a  liquid.  The  sound  meets  with  no  obstacle 
in  entering  the  stomach,  being  freely  movable  laterally.  Liquids 
usually  pass  through  the  esophagus  more  easily  than  solid  food. 
The  affection  is  often  difficult  to  distinguish  from  dilatation  of  the 
esophagus,  to  which  it  may  easily  lead. 

25 


386  DISEASES  OF  THE  ESOPHAGUS 

Treatment. — Attention  to  diet,  which  should  chiefly  be  liquid. 
If  necessary,  feeding  through  hollow  sounds.  Application  of  elec- 
tricity (faradization  of  the  esophagus),  or  strvchnin  injection 
0.001* Gm.  (-gV  grain). 

Atony. — Primary  atony  of  the  esophagus  may  develop  from  a 
neurotic  condition.  In  making  the  diagnosis  it  should  be  observed 
that  liquids  always  pass  without  hindrance,  while  solid  substances 
do  not.  There  is  no  difficulty  in  passing  the  sounds.  Organic 
affections  can  be  excluded  from  the  findings  obtained  through 
the  esophagoscope.  The  differential  diagnosis,  however,  between 
dilatation  and  atony  is  not  always  an  easy  matter. 

Treatment. — General  strengthening  measures;  hydrotherapy; 
arsenic;  iron;  faradization  of  the  esophagus;  adequate  nutrition. 


CHAPTER  XVII. 

MOTOR  NEUROSES. 

Vagotonia;  Sympathicotonia;  Hypermotility;  Peristaltic 
Unrest;  Cardiospasm;  Pylorospasm;  Eructations;  Pneumo- 
tosis;  Vomiting;  Rumination;  Regurgitation;  Pyloric 
Insufficiency;  Singultus  Gastricus. 

It  is  often  difficult  to  establish  a  diagnosis  of  a  purely  nervous 
or  functional  derangement  of  the  stomach — that  is,  to  be  certain 
that  no  organic  disease  is  present.  It  is  also  difficult  to  ascertain 
whether  or  not  the  fundamental  neurasthenia  lying  at  the  bottom 
of  every  neurosis  of  the  stomach  is  the  primary  cause. 

Neuroses  of  the  stomach  are  differentiated  from  organic  con- 
ditions by  the  one  predominant  symptom,  referable  to  the  motor, 
secretory,  or  sensory  functions.  This  symptom  has  been  termed 
"nervous  dyspepsia."  Some  writers  endeavor  to  draw  distinct 
lines  of  demarcation  between  motor  and  secretory  and  sensory 
neuroses,  and  speak  of  nervous  dyspepsia  as  a  disease  in  itself,  in 
which  there  may  be  present  combinations  of  motor,  secretory,  and 
sensory  disturbances,  giving  rise  to  purely  subjective  symptoms. 
Gastric  neuroses  develop  principally  in  individuals  of  a  nervous 
temperament  —  that  is,  in  neurasthenics,  hypochondriacs,  and 
hysterical  persons. 

THE  VEGETATIVE  NERVOUS  SYSTEM. 

Functional  derangement  of  the  gastro-intestinal  tract  can  be 
best  understood  by  a  study  of  the  visceral  nervous  system.  The 
innervation  is  supplied  from  three  sets  of  nerves:  first,  the  tonic 
or  motor  impulses,  transmitted  through  the  vagus;  second,  the 
inhibitory  impulses  through  the  sympathetic;  and  third,  inde- 
pendent impulses,  through  the  ganglionic  plexuses  of  Auerbach 
and  Meissner.  These  nerves  can  be  distinctly  stimulated  and 
distinctly  inhibited  by  certain  medicaments.  The  first  two  sets 
of  nerves  are  functionally  antagonistic,  and  in  correlation  have 
been  called  by  Langley  the  "vegetative  nervous  system" — a 
system  that  is  self-governing  and  entirely  independent  of  the 
impulses  which  originate  in  the  cells  of  the  cerebral  cortex.  They 
supply  the  smooth  muscle  and  all  the  secretory  glands  of  the 
digestive  organs.  Disturbance  in  the  equilibrium  of  these  nerves 
induces  the  classical  conditions  of  hypermotility  and  hypomotility, 
atony,  hypersecretion  and  hyposecretion,  with  their  accompanying 
symptoms. 


388  MOTOR  NEUROSES 

VAGOTONIA  AND  SYMPATHICOTONIA. 

In  contrast  with  the  central  nervous  system,  which  serves  the 
senses  and  the  muscles  controlled  by  the  will,  stands  the  vegetative 
nervous  system — under  which  term  we  include  all  nerve  fibers  which 
are  connected  with  organs  having  smooth  muscles,  such  as  the 
esophagus,  stomach,  intestine,  liver,  gall  bladder,  pancreas,  blood- 
vessels, gland  ducts,  and  skin,  as  well  as  the  nerve  structures  which 
determine  the  activity  of  the  glands  of  secretion.  Besides  these, 
certain  organs  are  included  in  the  system  which  have  cross-striated 
muscles,  such  as  the  heart,  cardia,  pylorus,  anus,  and  the  muscles 
of  the  genital  apparatus.  One  marked  distinction  between  the 
central  and  the  vegetative  nervous  systems  is  that  the  latter  has 
ganglionic  cells  interposed  in  the  course  of  the  nerve  distribution. 
This  characteristic  makes  it  possible  for  the  anatomist  and  the 
physiologist  to  definitely  separate  the  two  great  nervous  systems. 
When  vegetative  nerves  are  stimulated  at  their  origin,  definite 
manifestations  occur,  but  if  nicotin  be  painted  upon  a  ganglion 
between  the  site  of  stimulation  and  the  periphery  these  manifesta- 
tions cease  at  once.  The  functional  manifestations  of  the  central 
nervous  system  are  unaffected  by  nicotin. 

The  vegetative  nervous  system  embraces  the  sympathetic  and 
related  ganglia  supplying  the  organs  of  involuntary  bodily  function 
independent  of  the  central  nervous  system,  and  in  addition  the 
cranial  and  sacral  nerves.  One  part  of  the  system  is  supplied  by  the 
thoracic  cord  and  the  upper  area  of  the  lumbar  cord,  by  way  of  the 
sympathetic  ganglia,  while  another  part  originates  in  the  medulla 
and  the  sacral  segment  of  the  spinal  cord;  the  latter  is  called  the 
autonomic  or  extended  vagus  system. 

It  will  thus  be  seen  that  the  vegetative  nervous  system  consists 
really  of  two  great  systems — the  sympathetic  and  the  autonomic. 
The  viscera  are  innervated  by  both.  Both  are  under  the  control  of 
the  internal  secretions.  Electrical  investigations  show  that  mani- 
festations caused  by  stimulation  of  the  fibers  of  the  sympathetic 
may  be  counteracted  by  stimulation  applied  to  fibers  of  the  auto- 
nomic, and  vice  versa.  The  two  systems  seem  to  be  functionally 
antagonistic  to  each  other.  This  is  proved  pharmacologically. 
Epinephrin  acts  solely  upon  the  sympathetic  system;  its  action  is 
equivalent  to  stimulation  of  the  sympathetic  fibers.  The  autonomic 
system  can  also  be  influenced  by  drugs.  The  most  important  are 
atropin,  pilocarpin,  physostigmin,  and  muscarin.  It  is  known  that 
epinephrin  flows  continuously  from  the  adrenals  and  that  this 
internal  secretion  exerts  a  continuous  influence  upon  the  sym- 
pathetic nervous  system.  Eppinger  and  Hess  believe  that  there 
may  be  an  internal  secretion,  denominated  by  them  "autonomin," 
which  continuously  stimulates  the  autonomic  nervous  system. 
The  autonomic  nervous  system  stimulates  motility,  secretion,  and 


VAGOTONIA  AND  SYMPATHICOTONIA  389 

sensation,  while  the  sympathetic  inhibits  them.  When  both 
systems  act  harmoniously  and  arc  properly  balanced,  normal  bodily 
function  results.  If  for  any  reason  this  functional  equilibrium  is 
broken,  there  results  a  condition  of  variation  in  tonus,  depending 
upon  which  system  is  overstimulated — that  is,  a  condition  of  either 
vagotonia  or  sympathicotonia. 

From  overstimulation  of  the  autonqmic  nervous  system  we  have 
the  condition  known  as  vagotonia.  When  the  sympathetic  system 
is  overstimulated,  sympathicotonia  results.  Certain  drugs  induce 
antagonistic  action  by  stimulating  both  systems.  The  apposition 
of  the  two  systems  prevents  acute  transition  of  the  functions  of  the 
visceral  organs  from  one  extreme  to  the  other.  It  is  quite  possible 
that  there  exists  in  the  central  nervous  system  a  center  wrhich  con- 
trols the  antagonistic  action  of  these  two  systems.  It  is  clear  that 
a  disturbance  in  either  system  will  cause  an  increased  or  decreased 
tonus  in  the  other,  wThich  may  become  the  basis  for  the  development 
of  a  pathologic  condition. 

Sufficient  evidence  has  been  adduced  to  show  that  disturbance  of 
the  vegetative  nervous  system  plays  a  most  important  role,  not  only 
in  initiating  local  gastro-enteric  functional  defect,  but  also  in  con- 
trolling and  shaping  the  course  of  such  defect  to  the  point  of  profound 
organic  change. 

Excessive  stimulation  of  the  autonomic  nervous  system  causes 
spasm  of  the  circular  muscles  of  the  alimentary  canal.  This  over- 
stimulation may  induce  esophagospasm,  cardiospasm,  gastrospasm, 
pylorospasm,  enterospasm,  or  proctospasm.  Indeed,  an  excessive 
tonus  and  a  spastic  condition  of  separate  segments  of  the  gut  can 
result  in  chronic  spastic  constipation.  The  typical  vagotonic  never 
has  a  dry  mouth.  Attacks  of  sweating  are  associated  with  many 
other  conditions  of  increased  tonus  in  other  parts  innervated  by 
the  vagus,  such  as  nausea,  vomiting,  asthma,  angina  pectoris,  and 
gastric  crises. 

In  vagotonia  there  is  increased  tone,  peristalsis  and  secretion  of 
the  stomach.  The  cow-horn  stomach,  with  muscular  tone,  belongs 
to  the  vagotonic  individual.  Hypersecretion  and  hyperacidity  are 
traceable  to  stimulation  of  the  autonomic  nervous  system.  Pain 
is  a  common  accompaniment  of  this  condition.  Stimulation  of  the 
circular  pyloric  muscles  is  the  underlying  cause  of  pylorospasm. 
Esophagospasm  and  cardiospasm  are  both  typical  of  vagotonia. 
Muscular  spasm  of  the  stomach  induces  an  ischemia  of  the  gastric 
mucous  membrane,  with  loss  of  the  antiferment,  allowing  the  excess 
of  hydrochloric  acid  to  attack  the  mucosa,  when  accidental  infection 
may  lead  to  the  formation  of  gastric  ulcer.  The  initial  lesion  of 
peptic  ulcer  may  be  due  to  a  disturbance  of  the  vegetative  nervous 
system,  and  this  may  be  brought  about  by  a  disturbed  hormone 
balance  between  the  thyroid  and  adrenals.  G.  A.  Friedman  has 
proved  the  truth  of  this  statement  by  animal  experimentation; 


390  MOTOR  NEUROSES 

after  adrenalectomy,  parathyroidectomy,  or  repeated  injections  of 
thyroid,  pilocarpin  or  epinephrin,  lesions,  erosions  or  acute  ulcers 
developed  in  the  stomach. 

Both  diarrhea  and  constipation  result  from  vagotonia.  When  the 
longitudinal  muscle  fibers  are  involved,  diarrhea  occurs,  and  when 
the  circular  muscle  fibers  are  affected  the  result  is  spastic  constipa- 
tion. 

The  tender,  palpable  colon  is  a  prominent  sign  of  vagotonia.  In 
many  cases  the  small  masses  of  fecal  matter  are  covered  with  mucus. 
This  increased  secretory  activity  of  the  colon  induces  a  condition 
that  approaches  mucous  colitis.  We  regard  mucous  colitis  as  a 
secretory  neurosis  of  the  intestine,  because  atropin  has  such  a 
markedly  beneficial  action  upon  it.  The  cause  of  the  disease  does 
not  lie  in  the  intestinal  mucosa,  for,  though  we  call  the  condition 
mucous  colitis,  there  is  no  inflammation  of  the  colon.  The  cause 
undoubtedly  is,  in  many  instances,  some  disturbance  of  the  auto- 
nomic nervous  system.  Many  patients  suffering  from  mucous 
colitis  give  a  history  suggestive  of  prolonged  intestinal  spasm. 
Spastic  constipation  is  often  accompanied  by  spasm  of  the  anal 
sphincter  so  severe  as  to  prevent  defecation  that  would  otherwise 
occur.     The  patieDt  fears  the  pain. 

Epinephrin  stimulates  the  sympathetic  nervous  system  as  pilo- 
carpin stimulates  the  autonomic.  Numerous  investigations  have 
proved  that  there  exists  a  pharmacologic  antagonism  between 
epinephrin  and  pilocarpin. 

Atropin  paralyzes  the  peripheral  ends  of  the  autonomic  nerves, 
quieting  the  spastic  intestine.  The  action  of  the  drug  is  best 
observed  in  cases  of  increased  tonus  or  vagotonia  which  have  led 
to  increased  intestinal  peristalsis. 

Diagnostic  Phenomena  in  Disturbances  of  the  Vegetative  Nervous 
System. — A  classification  of  certain  groups  of  diseases  showing  a 
predominance  of  vagotonia  or  sympathicotonia  signs  is  not  very 
difficult.  Many  of  these  signs  and  symptoms  can  be  produced  by 
decreased  functioning  of  one  of  the  systems,  with  overfunctioning 
of  the  other.  The  following  are  a  few  of  the  many  tests  for  the 
recognition  of  vagotonia  and  sympathicotonia.  Aschner's  phe- 
nomenon (oculocardiac  reflex)  is  produced  by  continuous  pressure 
with  the  fingers  on  the  eyeballs  for  one-half  to  one  minute.  In  the 
normal  person  retardation  in  the  pulse-rate  follows,  but  rarely  to  a 
greater  degree  than  ten  beats  to  the  minute.  In  vagotonia  there  is 
a  marked  slowing  of  the  pulse  during  this  procedure,  and  at  times 
even  a  bradycardia. 

Hering's  phenomenon  is  evoked  by  slow,  deep  respirations. 
Normally  the  rate  and  volume  of  the  pulse  continue  practically 
constant  during  deep  inspiration  and  expiration.  In  vagotonia, 
inspiration  causes  an  increase  in  the  rate  of  the  pulse  and  a  decrease 
in  the  volume,  while  in  expiration  the  pulse  becomes  slower  and 


VAGOTONIA  AND  SYMPATHICOTONIA 


391 


increases  in  volume.  On  forced  inspiration  the  pupils  are  dilated, 
and  on  expiration  contracted. 

The  pilocarpin  test  consists  in  administering  0.006  Gm.  (TV  grain) 
of  pilocarpin  hypodermically.  In  sympathicotonia  no  salivation 
follows.  In  vagotonia  extreme  salivation  and  bronchial  secretion 
occur. 

Other  tests,  such  as  fat  tolerance,  carbohydrate  tolerance, 
epinephrin  sensitiveness,  and  cutaneous  sensitiveness,  have  been 
suggested.  This  whole  subject  is  of  such  great  importance  in  the 
diagnosis  and  treatment  of  neuroses  of  the  gastro-intestinal  tract 
that  I  have  tabulated  some  of  the  important  symptoms  and  signs 
suggestive  of  derangement  of  the  vegetative  nervous  system : 


Vagotonia. 
Miosis. 

Accommodation  spasm. 
Frequent  winking. 
Epiphora. 
Enophthalmos. 
Excessive  perspiration. 
Ptyalism. 

High  gastric  acidity. 
Achy  Ha. 

Gastro-intestinal  hypermotility. 
Spastic  constipation. 
Mucous  colic. 
Diarrhea,  occasionally. 
Bradycardia. 
Low  blood-pressure. 
Asthma. 

Cardiospasm,  pylorospasm. 
Enterospasm,  proctospasm. 
Status  lymphaticus. 
Gag  reflex  absent. 
Eosinophilia. 
Clammy  hands  and  feet. 
Dermographia. 
Aschner's   oculocardiac    reflex 

positive. 
Pilocarpin  test  positive. 
Increased  fat  tolerance. 
Graefe's  sign  positive. 


Sympathicotonia. 
Mydriasis. 

Accommodation  paralysis. 
Infrequent  winking. 
Dryness  of  eyeballs. 
Exophthalmos. 
Dryness  of  skin. 
Dryness  of  mouth. 
Low  gastric  acidity. 
Gastrorrhea. 

Gastro-intestinal  hypomotility. 
Atonic  constipation. 
No  mucous  colic. 
Diarrhea,  rarely. 
Tachycardia. 
High  blood-pressure. 
Urticaria. 
Gastric  atony. 
Intestinal  relaxation. 
Tonsils  atrophic. 
Gag  reflex  marked. 
Eosinopenia. 
Dry  hands  and  feet. 
No  dermographia. 
Aschner's  oculocardiac  reflex 

negative. 
Pilocarpin  test  negative. 
Steatorrhea. 
Mobius'  sign  positive. 


We  recognize  that  a  hypertonic  state  of  the  musculature  of  the 
stomach  and  intestine  is  a  constant  result  in  vagotonia.  There  is 
an  overcontraction  of  the  intestinal  canal,  which  is  manifested 
in  the  condition  known  as  spastic  constipation.  Upon  palpation 
the  sigmoid  may  be  felt  as  a  thick  cord.  The  anus  is  tight  and 
contracted.  These  patients  often  complain  of  abdominal  pain 
soon  after  meals.  Partaking  of  cold  liquids  may  induce  a  sudden 
attack  of  diarrhea,  with  excretion  of  a  large  quantity  of  mucus. 
The  colics  of  enteritis  membranacea  have  in  their  etiology  a  dis- 
turbance of  the  vegetative  nervous  system.    (See  Chapter  XXXVI.) 

Treatment. — In  the  treatment  of  all  the  neuroses  of  the  gastro- 
intestinal organs,  disturbance  of  the  visceral  nerves  deserves  careful 


392  MOTOR  NEUROSES 

consideration.  The  results  from  medical  treatment  have  proved 
eminently  satisfactory.  In  hyperacidity,  hypermotility,  cardio- 
spasm, pylorospasm,  enterospasm,  spastic  constipation,  and  enter- 
itis membranacea,  atropin  or  belladonna  is  our  sovereign  remedy — 
extract  of  belladonna  0.008  Gm.  (f  grain)  three  or  more  times  daily 
until  the  physiologic  action  of  the  drug  is  secured,  the  medication 
to  be  continued  until  the  throat  becomes  dry,  when  the  dose  should 
be  gradually  decreased.  Benzyl  benzoate  often  relieves  the  spasm 
(see  page  276). 

In  the  treatment  of  low  gastric  acidity,  gastric  and  intestinal 
atony,  constipation,  and  gastroenteroptosis,  pilocarpin  is  the  best 
remedy.  It  stimulates  the  branches  of  the  vagus  which  supply 
the  gastro-intestinal  organs,  and  is  consequently  vagotonic.  Pilo- 
carpin should  be  given  in  doses  of  0.0015  Gm.  (^  grain)  three  or 
more  times  daily  until  the  physiologic  action  of  the  drug  is  secured. 
The  annoying  itching  sometimes  present  is  rapidly  relieved. 

Regulation  of  diet,  hyperalimentation,  education  of  the  patient 
to  a  rational  mode  of  life,  hydrotherapeutics,  gymnastics,  elec- 
tricity, massage,  are  all  of  value.  The  physician  may  exercise 
a  profound  influence  over  the  patient's  mental  condition  when  he 
is  able  to  do  so;  the  progress  of  the  case  toward  recovery  will  be 
much  more  rapid  than  it  would  otherwise  be.  The  prognosis  will 
depend  largely  upon  the  duration  of  the  treatment,  which,  in  the 
majority  of  cases,  must  be  protracted. 

HYPERMOTILITY  (HYPERKINESIS). 

"Hypermotility"  is  a  term  which  designates  an  abnormally 
increased  movement  in  the  evacuation  of  the  stomach,  so  that 
the  viscus  is  often  found  empty  soon  after  the  ingestion  of  food. 
Hypermotility  may  occur  in  cases  of  achylia  gastrica,  the  closure 
of  the  pylorus  being  defective  on  account  of  the  diminution  or 
absence  of  hydrochloric  acid  secretion;  or  it  may  occur  with  any 
other  variety  of  pyloric  insufficiency.  It  is  a  frequent  accompani- 
ment of  duodenal  ulcer.  Cases  of  purely  neurogenous  hypermotility 
are  rare.  The  diagnosis  is  established  by  means  of  a  test  break- 
fast or  the  Roentgen  ray.  Hypermotility  does  not  often  give  rise 
to  distressing  symptoms,  and  consequently  does  not  require  any 
particular  treatment. 

PERISTALTIC  UNREST  OF  THE  STOMACH. 

The  complex  of  symptoms  first  described  by  Kussmaul,  and 
attributed  by  him  to  peristaltic  unrest  of  the  stomach,  does  not 
often  occur  as  a  pure  neurosis.  The  patients  experience  sensations 
of  constant  "griping  and  moving"  in  the  stomach  and  abdomen. 
When  the  abdominal  walls  are  thin  and  the  stomach  more  or  less 


CARDIOSPASM  393 

ptotic,  it  is  possible  for  the  examiner  to  discern  the  actual  peri- 
staltic movements  of  the  stomach.  These  movements  are  invisible 
through  the  abdominal  wall  when  the  stomach  is  in  its  normal 
position.  A  more  or  less  rapid  peristalsis  is  occasionally  accom- 
panied by  rolling  sounds  which  can  be  heard  at  some  little  distance 
from  the  patient.  This  condition  is  often  present  in  stenosis  of  the 
pylorus.  In  making  the  diagnosis,  mechanical  obstruction  about 
the  pylorus  must  be  ruled  out. 

Treatment. — The  treatment  consists  in  combating  the  cause  as 
well  as  the  general  nervous  symptoms  present.     In  stenosis  of 
the  pylorus  a  gastroenterostomy  is  indicated.    Excessive  exertion, 
either  mental  or  physical,  must  be  carefully  avoided.      Nutrition 
should  be  regulated  in  order  to  avoid  the  ingestion  of  anything 
that  might  irritate  the  stomach;  the  food  should  be  of  a  bland, 
semiliquid  nature,  and  too  great  a  quantity  should  not  be  allowed 
at  any  one  time,  for  fear  of  overdistending  the  stomach.     The 
evening  meal  should  be  light.     The  milk  cure,  combined  with 
rest  in  bed,  is  worthy  of  trial.    The  direct  local  treatment  consists 
of  either  cold  or  warm  applications  over  the  stomach,  with  lavage 
in  the  presence  of  dilatation  and  pyloric  stenosis.     Electric  treat- 
ment in  the  form  of  either  the  galvanic  or  faradic  current  may  be 
employed  (see  page  215).     Sometimes  confining  the  patient  to  bed 
and  resorting  to  rectal  feeding  gives  good  results,  owing  to  the 
physiologic  rest  thus  afforded  the  stomach.     A  two  weeks'  course  of 
nutrient  enemata  (see  page  243)  often  results  in  complete  recovery. 
The  drug  indications  include  the  use  of  the  bromids.     Strontium 
bromid,  1  Gm.  (15  grains)  four  times  a  day  in  water,  or  codein 
phosphate,  0.01  to  0.03  Gm.  (|  to  \  grain)  every  two  or  three  hours, 
may  be  prescribed  for  the  relief  of  pain.     Extract  of  belladonna, 
0.01  Gm.  (|  grain),  sometimes  affords  great  relief.     For  rheumatic 
patients  acetylsalicylic  acid  1  Gm.  (15  grains)  and  bismuth  sub- 
nitrate  1  Gm.  (15  grains),  three  times  a  day,  has  proved  beneficial. 
Vibratory  massage  over  the  left  side  of  the  tenth,  eleventh  and 
twelfth  dorsal  vertebras  has  also  given  relief  in  this  condition;  it 
should  be  performed  daily,  the  treatment  lasting  five  minutes. 

CARDIOSPASM. 

Cardiospasm  is  a  condition  in  which  a  spastic  contraction  occurs 
at  the  cardiac  orifice  of  the  stomach.  The  esophagus  becomes 
closed  up  at  its  junction  with  the  stomach  at  the  moment  of  swal- 
lowing, so  that  it  is  impossible  for  either  solids  or  liquids  to  enter 
the  gastric  cavity.  Under  normal  conditions  the  cardia  is  capable 
of  contraction  and  relaxation.  The  contractile  force  is  situated  in 
the  cardia  itself  through  the  vagus,  while  the  power  of  relaxation  is 
controlled  from  the  thoracic  ganglia,  whence  the  inhibitory  impulses 
proceed  to  the  cardia.     During  each  act  of  swallowing,  inhibi- 


394  MOTOR  NEUROSES 

tory  impulses  pass  from  the  sympathetic  to  the  cardia,  causing 
the  latter  to  open  to  receive  the  bolus  of  food.  In  cardiospasm 
this  inhibitory  control  is  apparently  absent,  so  that  the  cardia 
remains  in  a  state  of  continuous  contraction.  Cardiospasm  is 
probably  due  to  an  affection  of  the  vegetative  nervous  system. 

The  term  "achalasia,"  meaning  absence  of  relaxation,  has  been 
suggested  by  Hertz  as  descriptive  of  the  condition  commonly  known 
as  cardiospasm.  In  achalasia  a  rubber  tube  rilled  with  mercury 
will  drop  through  the  cardia  into  the  stomach  without  the  slightest 
difficulty,  thus  differentiating  this  condition  from  obstruction  caused 
by  a  growth. 

Symptoms. — Examination  of  the  cardia  in  this  condition  has 
revealed  hypertrophy  of  the  muscles  and  slight  atrophic  changes 
in  the  pneumogastric  nerve.  Cardiospasm,  as  a  rule,  starts  sud- 
denly during  eating,  and  may  pass  off  rapidly  (acute  cardiospasm) ; 
or  it  may  persist  for  a  long  time  (chronic  cardiospasm).  When 
the  condition  becomes  chronic,  patients  while  eating  experience 
a  sensation  of  pressure  in  the  chest,  which  at  times  assumes  the 
character  of  spastic  pains  radiating  toward  the  bowels.  The 
morsel  of  food  is  felt  sticking  in  the  esophagus,  only  to  pass,  after 
a  time,  into  the  stomach;  or  retching  may  cause  its  regurgitation 
into  the  mouth.  When  cardiospasm  of  this  character  continues 
for  any  considerable  length  of  time,  a  loss  in  weight  results,  due  to 
undernutrition.  Retained  food  causes  irritation  of  the  esophageal 
mucous  membrane,  and  the  esophagus  in  chronic  cases  becomes 
dilated  above  the  cardia.  ' 

Diagnosis. — The  diagnosis  of  cardiospasm  is  made  by  close  obser- 
vation of  both  subjective  and  objective  symptoms.  The  objective 
examination  consists  in  the  introduction  of  a  soft  stomach  tube 
or  esophageal  bougie,  which,  in  the  presence  of  cardiospasm,  is 
grasped  by  the  cardia  and  retained  by  the  spastic  muscular  con- 
traction. The  spasm  relaxes  only  after  a  period  of  waiting.  Under 
any  other  condition,  except  obstruction  by  benign  or  malignant 
growth,  the  cavity  of  the  stomach  may  be  easily  reached.  This 
phenomenon  is  characteristic  of  cardiospasm.  Dilatation  of  the 
esophagus  is  ascertained  by  the  presence  of  undigested  food  rem- 
nants. Another  feature  of  diagnostic  importance  is  the  fact  that 
the  so-called  second  sound  of  deglutition  appears  late  or  is  often 
absent  in  cardiospasm  (see  page  350).  Meltzer  refers  to  the  diag- 
nostic importance  of  the  inability  to  vomit.  The  diagnosis  may 
be  further  confirmed  by  esophagoscopy  and  Roentgen-ray  exami- 
nation (see  page  137).  Roentgenograms  (Plate  XI,  Fig.  1)  taken 
shortly  after  the  ingestion  of  the  bismuth  meal  show  the  constricted 
cardia,  with  dilatation  of  the  esophagus. 

Delineator  String. — Einhornand  Scholzhave  devised  a  delineator 
string  that  casts  a  definite  shadow  on  the  fluoroscopic  screen  or  on 
the  plate,  which  has  proved  to  be  of  great  value  in  the  diagnosis  of 


CARDIOSPASM 


395 


cardiospasm.  It  is  made  of  very  fine  copper  wires,  sixty  in  a  single 
strand,  which  is  covered  with  braided  silk;  a  metal  ball  is  attached 
to  one  end  of  the  string.  This  strand  of  copper  wires  otters  no 
resistance  whatever  to  spastic  movements  of  the  esophagus,  being  as 
pliant  as  a  piece  of  cotton  string.  It  is  introduced  into  the  esophagus 
in  the  same  manner  as  the  stomach  bucket  (see  page  72).  Under 
the  Roentgen  ray  the  shadow  of  the  string  appears  more  or  less 
tortuous,  according  to  the  degree  of  esophageal  spasticity  present. 
Alterations  in  the  outline  of  the  esophagus  from  time  to  time  are 
easily  recognized  by  the  roentgenologist  in  cases  of  intermittent 


Fig.   78. — Delineator  string  in  normal  individual. 


cardiospasm.  Once  the  delineator  string  has  been  introduced,  it 
may  be  allowed  to  remain,  so  that  the  roentgenologist  can  make  as 
many  examinations  as  he  pleases  without  subjecting  the  patient  to 
the  inconvenience  of  repeated  ingestions  of  barium  or  bismuth. 
(Figs.  78  and  79.) 

Prognosis. — The  prognosis  of  cardiospasm  is  always  uncertain. 
Acute  cardiospasm  occasionally  disappears  entirely,  or  reappears 
only  at  rare  intervals.  In  chronic  cardiospasm  the  prognosis 
is  less  favorable  for  complete  cure,  and  the  disease  must  always 
be  regarded  as  somewhat  serious  because  the  sacculation  above  the 
constriction  persists  indefinitely. 


396 


MOTOR  NEUROSES 


Treatment. — The  treatment  of  cardiospasm  consists  in  the  treat- 
ment of  the  neurotic  conditions  underlying  it.  The  psychic  factor 
of  treatment  is  important,  and  patients  must  be  reassured  by  the 
physician  that  the  dread  of  swallowing  which  is  always  present 
may  be  dismissed.  The  patient  should  be  prevailed  upon  to  per- 
form the  act  of  deglutition  several  times  without  any  food  in  the 
mouth  before  each  meal,  after  which  he  should  attempt  to  eat. 
His  attention  during  meals  should  be  diverted  from  his  condition. 
Change  of  location,  change  in  the  usual  habits  of  life,  as  well  as 
a  different  arrangement  of  the  meal  hours,  will  sometimes  be 


Fig.  79. — Delineator  string  in  patient  affected  with  cardiospasm. 


accompanied  by  favorable  results.  All  articles  of  diet  apt  to  irritate 
the  esophagus  should  be  avoided.  Patients  must  be  instructed  to 
eat  slowly  and  to  masticate  their  food  thoroughly.  Extremes  of 
temperature  in  food  and  beverages  should  be  avoided.  Liquids 
containing  much  carbon  dioxid,  as  well  as  acid  or  highly  seasoned 
foods,  are  not  well  borne  by  patients  in  this  condition.  It  is 
important,  likewise,  that  the  consistency  of  the  food  should  be 
liquid  or  semisolid,  though  sometimes  patients  can  swallow  solid 
food  to  better  advantage  than  liquid.  A  highly  nutritious  diet 
with  as  little  bulk  as  possible  should  be  the  rule  for  these  patients. 
Sometimes  nutritive  enemata  are  indicated,  and  may  be  given 


CARDIOSPASM  397 

for  more  or  less  prolonged  periods  of  time.,  affording  rest  to  the 
esophagus  and  eardia  (see  page  243). 

The  oil  cure  as  recommended  for  carcinoma  of  the  eardia  (see 
page  552)  should  be  employed  in  the  treatment  of  cardiospasm. 
Mayonnaise  and  almond  milk  may  be  substituted  for  olive  oil. 
Drug  treatment,  as  a  rule,  has  no  direct  effect  upon  the  spasm.  In 
selected  cases,  however,  extract  of  belladonna  has  given  fair  results. 
Suppositories  of  atropin  or  eumydrin  may  be  prescribed.  Cases 
of  mild  cardiospasm  quickly  improve  under  the  influence  of  a  nerve 
sedative.  Bromids  in  large  doses  are  also  indicated.  In  painful 
cases  benefit  has  been  derived  from  the  administration  of  milk 
of  almonds  with  the  addition  of  anesthesin.  Benzyl  benzoate  is 
very  advantageous  (see  page  276). 

Mechanical  Treatment. — Chronic  cardiospasm  should  be  treated 
along  mechanical  lines,  and  the  eardia  must  be  dilated  by  means  of 
sounds. 

Myer  has  devised  a  valuable  dilator  for  the  treatment  of  cardio- 
spasm. The  cardiac  end  of  this  instrument  consists  of,  from  within 
outward,  first  a  rubber  tube,  one-fourth  of  an  inch  in  diameter, 
closed  at  one  end  and  at  the  other  end  continuous  with  the  esopha- 
geal tube;  next,  extending  for  about  six  inches  up  and  around  this 
|-inch  tube,  and  made  air-tight  at  each  end,  is  a  casing  of  thin  rubber 
known  as  Penrose  rubber  tubing,  which  may  be  procured  in  three 
sizes — No.  1  and  No.  2  for  the  large  dilator  and  No.  2  and  No.  3 
for  the  small;  and  encasing  the  Penrose  rubber  tubing  is  a  bag 
made  of  ordinary  white  silk  with  a  diameter  of  about  three  cen- 
timeters (Fig.  80) .  The  size  to  which  the  dilator  can  be  distended 
depends  upon  the  limitation  offered  by  the  silk  bag.  The  outer 
covering  of  all  is  Penrose  rubber  tubing,  securely  fastened  by 
means  of  silk  at  either  end.  A  flexible  mandrin  consisting  of  a 
steel  cable  is  used  in  introducing  the  dilator,  and  removed  when 
the  latter  is  in  proper  position.  The  dilating  process  is  performed 
by  means  of  a  large  glass  or  metal  syringe  such  as  is  used  in  bladder 
irrigation.  The  syringe  should  be  of  at  least  150  Cc.  (gv)  capacity. 
Great  pressure  may  be  exerted,  overstretching  of  the  dilator  being 
prevented  by  the  silk  bag  or  collar.  When  the  sound  has  been 
introduced  as  far  as  the  cardiac  orifice,  the  rubber  bulb  is  distended 
by  water  pressure  from  the  syringe.  The  operation  is  to  be  repeated 
at  weekly  intervals. 

Large  esophageal  sounds  or  bougies  should  be  used,  and  left 
in  position  in  contact  with  the  stricture.  It  is  better  to  begin 
with  sounds  of  medium  size  and  to  increase  the  size  as  the  stricture 
yields  to  the  dilating  process.  The  metal  spiral  sound  of  Crawcour 
(Fig.  71)  has  also  been  employed;  owing  to  its  pliability  and  weight, 
this  sound  very  easily  passes  through  strictures  of  almost  any  degree. 
The  treatment  by  dilatation  must  be  continued  for  a  long  period  if 
satisfactory  results  are  to  be  obtained.     Esophageal  lavage  should 


398 


MOTOR  NEUROSES 


also  be  performed  during  the  process  of  dilating  the  esophagus. 
Other  methods  of  dilating  the  esophagus  are  fully  described  in 
Chapter  XVI. 

Electrotherapy. — Internal  galvanization  of  the  stomach  has  been 
employed  in  a  few  cases  of  cardiospasm.  Sometimes  relief  is  only 
to  be  procured  by  chloroform  narcosis. 


f\ 

— 

jjlil|||||ir 

I 

■4 

1 

"1 

IH'jMiJj 

/■ 

■       s,  ■    /:«-  s.V,<       .. 


Fig.  80. — Myer's  cardia  dilator:     A,  deflated;  B,  inflated;  a,  outer  rubber  bag; 
b,  silk  bag;  c,  inner  rubber  bag;  d,  rubber  tube;  e,  mandrin. 

Surgical  Treatment — Surgery,  too,  has  been  employed.  The 
cardia  has  been  forcibly  dilated  directly  from  the  opening  made  by 
gastrostomy.  Divulsion  of  the  sphincter  of  the  cardiac  orifice  has 
been  done.  Willy  Meyer  reports  successful  treatment  by  thora- 
cotomy and  esophagoplication. 


PYLOROSPASM. 

Secondary  pylorospasm  is  of  comparatively  frequent  occurrence. 
Recent  studies  of  the  autonomic  nervous  system  would  seem  to 
point  to  the  probability  of  spasm  of  the  pylorus  being  sometimes 
of  purely  nervous  origin.  The  diagnosis  may  be  established  by 
exclusion  of  the  usual  causes  of  secondary  spasm  of  the  pylorus, 
such  as  carcinoma,  gastric  ulcer,  duodenal  ulcer,  gall-bladder 
disease,  appendicitis,  and  secretory  disturbances.  Pylorospasm 
from  vagus  overfunctioning  may  cause  delay  in  emptying  of  the 
gastric  contents,  and  this  is  usually  associated  with  hypersecretion 
(see  Chapter  XXI).    Pylorospasm  occasions  pain  of  greater  or  less 


PYLOROSPASM  399 

severity,  together  with  increased  gastric  peristalsis  and  sometimes 
vomiting.  Secondary  pylorospasm  may  be  caused  by  ulcer  of 
the  pylorus  or  duodenum,  when  the  excessive  acidity  induces  a 
spastic  contraction — usually  an  hour  or  more  after  meals,  at  the 
time  the  acid  enters  the  duodenum.  This  has  been  called  by 
Moynihan  "hunger  pain"  and  by  surgeons  is  regarded  as  diagnos- 
tic of  duodenal  ulcer.  There  are  many  other  conditions,  however, 
that  will  induce  pylorospasm,  and  therefore  "hunger  pain"  does 
not  possess  the  certain  diagnostic  value  which  many  would  have 
us  believe.  We  occasionally  find  pylorospasm  in  gastritis,  duo- 
denitis, cholecystitis,  appendicitis,  uterine  disease,  eye-strain,  and 
anomalies  of  secretion.  The  Roentgen  ray  (see  Chapter  V)  will 
often  assist  in  the  differentiation  between  primary  and  secondary 
pylorospasm.  The  symptoms  of  pylorospasm  are  found  in  cases  of 
hypercnlorhydria  (see  Chapter  XX).  In  a  case  of  chronic  appendi- 
citis I  was  able  to  induce  pylorospasm  and  epigastric  pain  by  pres- 
sure over  McBurney's  point  under  the  guidance  of  the  fluoroscope 
(see  Aaron's  sign,  page  773). 

The  differentiation  between  organic  obstruction  of  the  pylorus 
and  pylorospasm  is  frequently  quite  difficult.  One  of  the  best 
methods  of  determining  the  patency  of  the  pylorus  is  the  use  of 
the  Einhorn  duodenal  bucket  (Fig.  8).  This  is  a  small  gold  bucket, 
similar  in  shape  to  the  stomach  bucket,  attached  to  a  silk  cord. 
The  bucket  is  placed  in  a  capsule  and  swallowed  by  the  patient, 
and  not  withdrawn  for  several  hours.  On  withdrawal,  the  contents 
of  the  bucket  are  examined  for  pancreatic  ferments,  and  if  these 
are  found  we  are  reasonably  sure  the  bucket  has  been  in  the  duo- 
denum, thus  proving  that  the  pylorus  is  still  patent.  "When  the 
bucket  has  entered  the  duodenum  the  thread  near  it  is  golden 
yellow,  due  to  the  presence  of  bile.  It  is  important  that  the  stain 
on  the  thread  extend  only  a  short  distance  (10  to  15  centimeters). 
If  one-third  or  more  of  the  thread  is  bile-stained,  this  would  indi- 
cate a  regurgitation  of  bile  into  the  stomach,  and  therefore  forbid 
any  conclusion  regarding  the  passage  of  the  bucket  through  the 
pylorus.  The  bucket  will  never  reach  the  duodenum  when  there 
is  an  organic  pyloric  stenosis,  while  in  pylorospasm  it  passes  through 
(see  page  479) . 

The  diagnosis  of  pylorospasm1  can  be  made  with  the  delineator 
string  (Figs.  76  and  77)  just  as  the  diagnosis  of  cardiospasm  is 
made  (see  page  394).  It  is  better  to  introduce  the  delineator 
string  in  the  evening  and  leave  it  in  situ  over  night.  The  Roentgen- 
ray  examination  takes  place  the  following  morning.  If  the  metallic 
ball  is  still  in  the  stomach  the  obstruction  is  probably  of  an  organic 
nature.  Under  normal  conditions  the  metallic  ball  should  be  in  the 
intestine  and  the  course  of  the  string  presents  a  curved  line  accord- 

1  M.  Einhorn  and  T.  Scholz:  Roentgen  Ray  Findings  with  the  Delineator  in 
Cases  of  Pylorospasm,  Medical  Record,  November  27,  1920. 


400  MOTOR  NEUROSES 

ing  to  the  individual  position  of  the  organs.  This  line,  though 
curved,  is  even,  without  any  irregular  zigzagging.  If  there  is  a 
spastic  condition  at  the  pylorus  the  Roentgen  ray  shows  the  delinea- 
tor string  irregular,  corresponding  to  the  degree  of  spasticity. 

Treatment. — The  treatment  of  pylorospasm  consists  in  the  re- 
moval of  the  underlying  cause.  This  may  require  surgical  interven- 
tion or,  among  other  things,  the  application  of  heat,  the  adminis- 
tration of  bromids  and  belladonna,  codein,  galvanization,  and 
mild  hydrotherapeutic  measures.  Stockton  reports  excellent  results 
after  the  hypodermic  injection  of  1  Cc.  (16  minims)  of  1:1000 
epinephrin  solution.  Papaverin  hydrochlorid  diminishes  the  tonus 
of  the  gastric  musculature  without  exerting  any  influence  on  peri- 
stalsis. It  is  a  valuable  therapeutic  agent  in  the  dose  of  0.03  to  0.06 
Gm.  (|  to  1  grain)  three  times  daily.  Benzyl  benzoate  in  alcoholic 
solution  is  beneficial  (see  page  276).  A  bland,  non-irritating  diet 
should  be  prescribed,  such  as  that  recommended  in  the  treatment 
of  gastric  ulcer,  and  only  small  quantities  at  a  time  allowed  during 
the  initial  stages  of  treatment  in  order  to  avoid  overdistention  of  the 
stomach. 

The  oil  treatment,  as  outlined  by  Cohnheim,  is  valuable  (see 
page  481).  The  oil  should  be  taken  on  the  fasting  stomach.  Hyper- 
chlorhydria  is  frequently  the  cause  of  pylorospasm;  the  treatment 
of  this  condition  is  outlined  in  Chapter  XX;  atropin  and  eumydrin, 
together  with  the  ajkalis,  are  useful  in  pylorospasm  due  to  hyper- 
acidity. It  has  been  maintained  that  the  so-called  congenital 
stenosis  of  the  pylorus,  or  the  pylorospasm  of  infants,  is  caused  by 
marked  hyperacidity  or  hypersecretion  of  gastric  juice,  secondary 
to  congenital  neurosis.  An  early  diagnosis  of  the  condition  might 
possibly  be  obtained  by  examination  of  the  gastric  contents  of  the 
vomiting  infant  for  hyperacidity,  and  many  cases  be  thus  saved 
from  a  fatal  termination. 

Einhorn's  method  of  dilating  the  pylorus  by  means  of  a  thin 
stomach  tube  and  a  small  rubber  bag  should  be  employed  if  neces- 
sary. In  the  Einhorn  pyloric  dilator  (Fig.  82,  page  485)  a  small 
metal  end-piece  is  attached  to  a  thin  rubber  tube  (8  millimeters 
in  circumference  and  1  meter  long)  bearing  markings :  I  =  40  cm. ; 
II  =  56  cm.;  Ill  =  70  cm.;  and  80  cm.  Adjoining  the. metal  end- 
piece  and  fastened  to  it  and  the  tube  is  a  tiny  rubber  balloon  covered 
with  silk  gauze.  The  tube  has  a  few  perforations  in  the  space 
covered  by  the  balloon,  and  is  connected  at  its  upper  end  with  a 
graduated  glass  syringe  which  serves  the  purpose  of  inflating  the 
balloon  with  air. 

Tecknic. — The  pyloric  dilator  is  introduced  in  the  same  manner 
as  the  duodenal  tube  (see  page  501).  After  emptying  the  rubber 
balloon  of  its  air  contents  (this  is  done  by  drawing  the  piston  of  the 
syringe  outward) ,  the  cock  is  closed.  The  end-piece  of  the  dilator  is 
now  dipped  in  lukewarm  water  and  introduced  into  the  pharynx  of 


NERVOUS  ERUCTATION  401 

the  patient.  The  patient  drinks  some  water,  and  the  instrument 
moves  into  the  stomach.  It  is  now  left  in  the  digestive  tract  for 
several  hours;  or,  better,  it  is  swallowed  before  the  patient  retires, 
and  left  undisturbed  overnight — for  in  pylorospasm  it  sometimes 
takes  a  long  time  for  the  apparatus  to  pass  into  the  duodenum. 
In  the  morning  the  stretching  is  performed.  Before  doing  this 
it  is  necessary  to  ascertain  whether  the  dilator  is  in  the  duodenum. 
This  is  done  by  estimating  the  length  of  tubing  within  the  digestive 
tract  (it  should  be  in  as  far  as  mark  III,  or  70  cm.);  on  drawing 
the  tube  slightly"  outward,  it  usually  shows  mark  II  within  the 
mouth.  The  balloon  is  then  inflated  by  means  of  the  syringe.  If 
the  tube  be  now  drawn  forward  there  is  a  sensation  as  if  the  end 
of  the  instrument  wrere  held  tight  by  something  that  drags  along 
with  it,  not  being  able  to  escape  it.  It  is  not  permissible  to  use  much 
force.  The  balloon  is  then  slightly  deflated.  This  is  repeatedly 
done  until  the  end  of  the  dilator  by  a  slight  pull  passes  through 
the  pylorus.  The  swinge  being  graduated,  one  notes  the  number 
of  cubic  centimeters  of  air  in  the  balloon  during  its  passage  through 
the  pylorus.  While  the  dilator  is  being  drawn  through  the  stomach 
no  resistance  is  felt  until  the  cardia  is  reached.  Here  the  dilator 
should  be  entirely  deflated  and  withdrawn — which  is  accomplished 
without  trouble.  Should,  however,  resistance  be  encountered  at 
the  introitus  esophagi,  the  patient  should  swallow,  and  while  his 
larynx  moves  upward  the  instrument  is  gently  withdrawn  without 
the  application  of  any  force. 


NERVOUS  ERUCTATION  (AEROPHAGY). 

This  condition  is  characterized  by  belching,  which  appears  to 
be  independent  of  the  reception  of  food;  it  consists  in  eructations 
of  air,  accompanied  by  sounds  which  are  audible  at  a  consider- 
able distance  from  the  patient.  The  belching  may  persist  for 
hours  and  in  a  few  cases  it  has  been  reported  to  have  kept  up 
for  days.  The  condition  is  one  which  affects  chiefly  neurotic 
individuals  with  or  without  gastro-intestinal  disease.  Such  indi- 
viduals are  known  to  have  a  habit  of  eating  or  swallowing  air 
(aerophagy).  Neurotics  suffering  from  digestive  diseases  some- 
times experience  trifling  discomfort  in  the  stomach  which  they 
attribute  to  an  accumulation  of  gas,  and  in  their  efforts  to  obtain 
relief  they  expel  whatever  the  stomach  contains,  whether  "gas"  or 
atmospheric  air,  and  in  the  act  swallow  more  air.  When  patients  are 
suffering  from  some  gastro-intestinal  disturbance,  the  proteins  or 
carbohydrates  are  apt  to  decompose,  producing  some  little  gas. 
The  pressure  induced  by  this  gas  is  readily  relieved  by  belching. 
The  patient  remembers  the  great  relief  thus  obtained,  and  when  he 
has  a  similar  attack  of  gastric  weight,  pressure,  distention  or  pain, 
26 


402  MOTOR  NEUROSES 

his  first  thought  is  to  get  relief  by  raising  the  gas  from  the  stomach. 
An  effort  is  required  and  in  the  effort  the  patient  unconsciously 
swallows  air,  allowing  it  to  come  back  quickly  after  each  expulsive 
contraction  of  the  stomach,  and  thus  he  becomes  an  aerophagic. 

During  an  acute  aerophagic  attack,  patients  may  suffer  from 
dyspnea,  tachycardia,  and  cyanosis.  These  are  instantly  relieved 
by  introducing  the  stomach  tube,  which  allows  the  air  to  escape. 
The  distention  of  the  stomach  with  air  pushes  the  apex  of  the  heart 
upward  and  to  the  left.  This  pressure  on  the  ventricles  rotates  the 
heart  on  its  axis  and  distorts  the  great  vessels  at  its  base.  The  dis- 
tended stomach  or  esophagus  may  disturb  the  heart  in  a  reflex 
manner  because  the  common  innervation  of  these  organs  is  through 
the  vagi.  Stimulation  of  the  vagi  causes  a  slowing  of  the  heart. 
These  factors  often  produce  cardiac  arrhythmias  which  may  cause 
the  patient  considerable  worry  and  anxiety. 

Diagnosis. — The  diagnosis  of  this  condition  is  not  difficult  when 
the  physician  has  an  opportunity  to  observe  the  patient  during  a 
spell  of  eructation.  The  presence  of  food  decomposition  in  the 
stomach  should  be  ruled  out  by  examination  of  gastric  contents 
removed  by  the  tube.  By  close  observation  the  physician  will 
notice  that  the  patient  collects  a  little  saliva  in  his  mouth,  slightly 
flexes  the  head  on  the  thorax,  closes  his  mouth,  and  swallows.  By 
this  procedure  the  air  is  forced  into  the  esophagus,  producing  a 
sound  which  leads  the  patient  to  believe  that  the  act  is  an  eructa- 
tion, while  just  the  opposite  is  the  case.  On  opening  the  mouth 
the  air  is  noisily  belched,  and  then  swallowing  and  eructation 
follow  closely  upon  each  other  almost  continuously.  At  times  it 
requires  eight  or  ten  swallowings  of  air  to  induce  one  good  eructation. 

Treatment. — The  treatment  of  this  condition  is  largely  psychic, 
and  the  physician  must  impress  upon  the  patient  the  fact  that 
he  can  prevent  the  condition  himself  if  he  will.  The  nature  of 
the  affection  should  be  carefully  explained  to  the  patient,  and  he 
should  be  prevailed  upon  to  cease  the  eructation  as  well  as  the 
frequent  swallowing  movements.  The  French  recommend  that 
the  patient  take  a  cork  between  his  teeth  to  keep  the  mouth  open; 
this  is  done  after  every  meal,  and  the  practice  continued  for  a 
considerable  length  of  time.  While  the  mouth  is  open  the  patient 
cannot  swallow  air,  and  the  eructations  quickly  cease.  The  patient 
can  be  instructed  to  wear  a  tight  collar  so  that  the  pain  of  swallow- 
ing will  attract  his  attention  to  the  act.  Then  again,  in  order 
to  keep  the  thyroid  cartilage  from  rising,  one  may  tie  a  ribbon 
moderately  tight  around  the  neck;  this  is  not  only  a  direct  restraint 
but  serves  as  a  reminder  to  the  patient. 

'  Hyperalimentation  is  known  to  have  a  salutary  effect  upon 
weakened  patients.  Methodic  treatment  by  sounds  introduced  into 
the  esophagus  is  sometimes  followed  by  beneficial  results.  The 
underlying  nervous  condition  will  in  many  cases  yield  to  electricity, 


NERVOUS  VOMITING  403 

change  of  climate,  or  hydrotherapeutics.  The  medicinal  agents 
indicated  in  this  condition  consist  of  the  bromids,  belladonna, 
chloroform  water,  and  preparations  of  valerian. 

PNEUMATOSIS   (DRUM-BELLY). 

This  term  is  used  to  designate  a  condition  in  which  the  stomach 
is  greatly  distended  by  air.  The  patient  experiences  symptoms 
which  are  referable  to  the  heart,  such  as  irregularity  in  rhythm, 
and  dyspnea,  as  well  as  abdominal  tension.  Pneumatosis  of  a 
purely  nervous  character  is  due  to  the  habit  of  swallowing  air. 
Sometimes  the  condition  is  associated  with  simultaneous  spasmodic- 
closure  of  the  pylorus  and  cardia,  which  renders  it  impossible  for 
the  air  to  escape.  The  distressing  symptoms  usually  vanish  with 
the  expulsion  of  the  air. 

Treatment. — Pneumatosis  is  treated  as  are  nervous  eructations. 
The  treatment  should  be  directed  toward  increasing  the  strength 
of  the  organism  as  a  whole.  The  drug  treatment  consists  in  the 
administration  of  bromids,  cocain,  and  morphin,  the  latter  either 
orally  or  hypodermic-ally.  The  stomach  tube  will  give  immediate 
relief  by  allowing  the  air  to  escape. 

NERVOUS  VOMITING. 

Nervous  vomiting  produced  by  disturbances  of  the  nervous 
system,  both  central  and  peripheral,  without  external  irritation 
or  anatomic  lesion,  is  a  purely  functional  disorder.  It  occurs 
without  any  overexertion  and  is  independent  of  the  quantity  and 
quality  of  the  food  ingested.  It  varies  in  relation  to  the  different 
kinds  of  diet;  is  often  absent  when  articles  difficult  of  digestion 
have  been  eaten,  and  may  be  present  when  only  suitable  food  has 
been  taken. 

Organic  diseases  of  the  central  nervous  system  are  not  infre- 
quently accompanied  by  vomiting  of  this  nature.  The  gastric 
crises  of  tabetic  patients  are  of  peculiar  interest  in  connection  with 
this  subject.  They  occur  as  a  very  early  symptom  of  locomotor 
ataxia,  and  consist  of  violent  attacks  of  vomiting,  usually  accom- 
panied by  intense  gastric  pain  (gastric  crises).  The  vomiting 
may  last  for  days,  placing  the  patient  in  a  very  grave  condition. 
There  are  also  purely  motor  gastric  crises,  which  run  their  course 
without  any  sensation  of  pain,  vomiting  being  the  only  distressing 
symptom.  This  latter  condition  is  not  responsive  to  treatment, 
which  should  be  directed  against  the  cause  rather  than  the  symp- 
tom.    The  cause,  in  a  large  majority  of  cases,  is  syphilis. 

A  few  writers  have  described  attacks  of  what  they  term  idio- 
pathic vomiting,  which  resembled  very  closely  the  gastric  crises, 
and  in  which  they  were  unable  to  detect  any  pathologic  condition 


404  MOTOR  NEUROSES 

of  the  spinal  cord.  Nervous  vomiting  is  also  frequently  found  in 
hysterical  patients  and  in  neurasthenics;  it  adds  sometimes  to 
the  distressing  symptoms  of  patients  suffering  from  enteroptosis, 
atony,  and  nervous  dyspepsia.  Organic  diseases,  however,  must 
be  excluded  before  a  diagnosis  can  be  established.  Nervous 
vomiting  is  very  characteristic.  It  takes  place  with  seeming  ease, 
without  preceding  nausea;  it  is  likewise  independent  of  the  quality 
of  the  food,  but  largely  influenced  by  psychic  causes.  The  general 
nutrition  is,  as  a  rule,  easily  maintained. 

Treatment. — The  treatment  of  vomiting  of  purely  nervous  origin 
is  identical  with  that  of  neurasthenia,  hysteria,  and  enteroptosis. 
In  the  presence  of  obstinate  vomiting,  recourse  may  be  had  to 
drug  treatment,  when  such  sedatives  as  cocain,  menthol,  morphin, 
chloral  hydrate,  valerian,  validol,  menthol-valerian,  chloroform  on 
ice,  orthoform,  or  anesthesin  may  be  used  (see  page  270). 

Bismuth  is  one  of  the  best  drugs  for  the  treatment  of  that  class 
of  vomiting  which  results  from  gastric  irritation  (see  page  265). 
Cerium  oxalate  has  probably  the  same  action  in  allaying  vomiting 
as  bismuth.  It  has  acquired  a  reputation  in  the  treatment  of  the 
vomiting  of  pregnancy  which  clinical  experience,  as  a  rule,  fails 
to  confirm.  Creosote,  iodin  and  phenol  may  be  grouped  together 
as  a  series  of  drugs  which  allay  vomiting  that  is  produced  by  fer- 
mentative action  in  the  stomach.  The  vomiting  ceases  upon 
removal  of  the  cause.  Hydrocyanic  acid  in  small  doses  is  another 
drug  with  a  reputation  in  gastric  vomiting;  if,  however,  results 
are  not  obtained  immediately,  it  is  useless  to  persist  with  it. 
Aconite,  in  rather  large  doses,  allays  vomiting  by  inhibiting  the 
reflex  centers  and  thereby  acting  as  a  powerful  sedative  to  the 
peripheral  nerves  in  the  gastric  mucous  membrane.  It  is  one  of 
the  host  of  drugs  suggested  for  the  vomiting  of  pregnancy.  Chlore- 
tone  in  doses  of  0.3  to  0.5  Gm.  (5  to  8  grains)  relieves  pain  and 
often  allays  vomiting.  For  relief  of  the  vomiting  and  pain  of  gastric 
crises,  coryfin  in  10-drop  doses  every  two  hours  is  often  of  great 
service.  When  vomiting  is  of  reflex  origin  it  is  worth  while  to 
persist  with  potassium  bromid,  which  may  be  given  per  rectum  if 
not  tolerated  by  the  stomach.  Vomiting  in  sea-sickness  has  been 
quickly  relieved  by  inhibiting  the  vagus  by  the  hypodermic  injec- 
tion of  one  or  two  doses  of  atropin  0.001  Gm.  (gV  grain).  Chlore- 
tone  in  doses  of  0.3  to  0.7  Gm.  (5  to  10  grains),  given  by  mouth, 
has  acquired  considerable  reputation  as  a  preventive  of  sea-sickness. 

Hyperemesis  or  pernicious  vomiting  in  pregnancy  has  yielded 
to  treatment  with  epinephrin.  Ten  drops  of  a  1:1000  solution 
were  given  every  morning  and  night,  at  first  in  an  enema  of  150 
Cc.  (5  ounces)  of  water,  with  20  drops  of  tincture  of  opium,  and 
after  three  days  in  ice-water  by  mouth.  Curtis  has  had  success  in 
an  obstinate  case  by  the  injection  of  blood  from  a  normal  pregnant 
woman.     He  injected  10  Cc.  (5  iiss)  of  defibrinated  blood  into  the 


RUMINATION  405 

muscles  of  the  back  every  two  days.  Recovery  took  place  after 
three  injections.  Transfusing  the  patient  with  the  blood  of  a  nor- 
mal postpartum  woman  will  often  relieve  the  exhausting  vomiting 
and  enable  the  patient  to  go  over  to  full  term.  Good  results  are  also 
reported  from  the  hypodermic  administration  of  soluble  extract  of 
corpus  luteum,  20  milligrams  (\  grain)  in  1  Cc.  (10  minims)  of  saline 
solution,  the  dose  being  given  twice  daily  if  necessary,  Garnett 
believes  that  pregnant  women  develop  an  antigen  which  protects 
them  from  the  toxins  incident  to  the  progress  of  pregnancy. 
Patients  who  are  attacked  with  pernicious  vomiting  have  failed  to 
develop  the  specific  antigen. 

Persistent  nervous  vomiting  will  often  produce  acute  irritation 
of  the  stomach.  The  important  point  is  to  get  the  irritated 
stomach  to  retain  food.  Even  the  retention  of  a  liquid  may  break 
the  vicious  circle.  If  a  single  feeding  can  be  kept  down,  the  stomach 
will  soon  be  able  to  stand  another  and  more  nutritious  one.  Some- 
times a  tablespoonful  of  brandy  poured  over  another  tablespoonful 
of  cracked  ice  will  act  wonderfully  well. 

Opium  may  be  administered  in  the  form  of  suppositories.  Mor- 
phin  hypodermically  administered  acts  as  a  powerful  sedative  to 
the  vomiting  center,  and  will  afford  relief  in  persistent  and  exhaust- 
ing hyperemesis  as  definitely  as  it  does  in  a  paroxysm  of  pain. 

Pressure  or  percussion  of  the  fifth  dorsal  vertebra  for  one-half 
minute  will  often  relieve  the  vomiting  of  pregnancy.  This  manipu- 
lation acts  on  the  pyloric  reflex  and  opens  the  pylorus  (see  page  211). 
The  patient  drinks  a  glass  of  water  with  1  Gm.  (15  grains)  of  sodium 
bicarbonate.  Any  member  of  the  household  is  taught  to  strike  a 
series  of  moderate  blows  on  the  fifth  dorsal  vertebra,  which  has  been 
definitely  located  and  marked.  This  manipulation  is  equivalent  to 
duodenal  lavage.  After  resting  a  few  minutes  until  the  nausea  is 
abated,  nourishment  is  given  and  the  vertebra  is  again  percussed. 

Suggestive  or  psychic  therapeutics  and  the  use  of  gastric  lavage, 
simple  sounding  and  intraventricular  galvanization  have  all  pro- 
duced favorable  results  with  hysterical  patients.  It  must  not  be 
forgotten  that  nervous  vomiting  is  sometimes  induced  reflexly  by 
a  pathologic  condition  of  other  organs. 


RUMINATION  (MERYCISM). 

Rumination  is  an  unhappy  faculty  possessed  by  some  patients 
by  which  they  can  at  will  bring  back  the  food  from  the  stomach 
to  the  mouth  some  time  after  it  has  been  swallowed,  to  be  again 
swallowed  or  expectorated.  It  is  more  common  in  males  than  in 
females.  It  affects  neurasthenics,  hysterical  and  epileptic  persons, 
and  sometimes  idiots.  In  this  class  of  patients  rumination  some- 
times results  from  fright,  rapid  eating,  overfilling  of  the  stomach, 


406  MOTOR  NEUROSES 

traumatism,  or  irritation  of  the  stomach  by  chemical  or  thermic 
agents.  It  has  been  observed  to  develop  in  other  patients  by  mere 
imitation;  children  of  parents  who  ruminate  are  likely  to  indulge 
in  the  pernicious  practice.  The  exciting  causes  mentioned  induce, 
reflexly,  anti-  or  retro-peristaltic  movement,  which  results  in  the 
opening  of  the  cardiac  orifice,  permitting  the  food  to  regurgitate 
to  the  mouth. 

Rumination  is  frequently  preceded  by  nervous  dyspeptic  symp- 
toms of  a  mild  nature,  which  become  gradually  aggravated  until 
the  fluid  contents  of  the  stomach  are  regurgitated.  The  voluntary 
regurgitation  of  food  is  not  accompanied  by  nausea,  and  in  many 
cases  produces  no  discomfort  whatever.  In  other  cases,  however, 
the  food,  having  remained  for  a  considerable  length  of  time  in  the 
stomach,  has  become  sour  and  disagreeable  to  the  taste  when  regur- 
gitated; the  patients,  annoyed,  naturally  spit  it  out.  As  might  be 
expected,  the  habitual  expectoration  of  food  masses  leads  to  marked 
emaciation  of  the  patient.  In  these  cases  the  secretion  of  gastric 
juice  may  show  great  variation  from  the  normal,  or  it  may  be 
perfectly  normal. 

Treatment. — Psychotherapeutics  must  be  resorted  to  as  the 
chief  factor  in  the  treatment  of  these  cases.  The  patient  must 
be  energetically  persuaded  to  suppress  the  regurgitation  of  food. 
The  nervous  condition  underlying  the  pernicious  habit  requires 
appropriate  treatment.  As  a  prophylactic  measure,  patients 
should  be  instructed  to  eat  slowly  and  to  thoroughly  masticate 
their  food.  Such  patients  should  not  be  left  alone,  either  during 
the  meal  or  for  some  little  time  afterward,  since  the  presence  of 
company  imposes  a  salutary  restraint  on  the  ruminating  habit. 
When  the  desire  to  ruminate  arises,  expiration  of  air  should  be  post- 
poned for  a  moment  or  two  and  swallowing  movements  suppressed. 
Patients  should  not  talk  while  eating.  It  is  important  that  defec- 
tive teeth  be  either  repaired  or  extracted.  Children  should  be 
kept  away  from  ruminants  in  order  to  avoid  contracting  the  habit 
by  imitation.  Good  results  have  followed  the  administration  of 
acids  in  achylia,  and  large  doses  of  alkalis  in  hyperacidity.  Some- 
times the  patient  experiences  pain  of  greater  or  less  severity  in  the 
region  of  the  stomach  when  he  attempts  to  suppress  the  practice 
of  rumination,  and  in  such  cases  warm  applications  or  supposito- 
ries in  which  narcotic  drugs  are  incorporated  assist  in  relieving 
the  distress.  The  bromids  and  strychnin  are  also  indicated.  The 
chief  requirement  in  the  treatment  of  this  form  of  gastric  neurosis 
is  to  fortify  the  will-power  of  the  patient  sufficiently  to  suppress 
the  practice. 

REGURGITATION. 

Regurgitation  proper  is  a  condition  in  which  the  food  returns 
involuntarily  from  the  stomach  to  the  mouth  and  is  expectorated. 


INSUFFICIENCY  OF  THE  PYLORUS  407 

It  may  occur  in  health,  but  becomes  pathologic  when  it  persists 
over  a  prolonged  period  and  when  the  quantity  of  food  brought 
up  is  large.  Emaciation  results  when  patients  regurgitate  any 
considerable  portion  of  the  food  ingested.  The  treatment  of  this 
condition  is  similar  to  that  of  rumination. 


INSUFFICIENCY  OF  THE  PYLORUS. 

r 

Pyloric  insufficiency  is  a  condition  which  has  been  known  fre- 
quently to  follow  organic  diseases.  It  has  been  noted  after  destruc- 
tion of  the  pyloric  sphincter  by  carcinoma  or  by  pyloroplasty;  cica- 
trices from  gastric  ulcer  in  the  region  of  the  pylorus;  duodenal 
stenosis;  catarrh  of  the  stomach;  and  achylia.  Pyloric  insufficiency 
from  purely  neurotic  causes  is  of  exceedingly  rare  occurrence. 
Among  the  most  important  diagnostic  indications  of  pyloric  insuf- 
ficiency is  the  fact  that  air  blown  into  the  stomach  escapes  immedi- 
ately into  the  gut,  thus  rendering  artificial  distention  of  the  stomach 
impossible.  The  flow  of  bile  and  of  the  contents  of  the  small  intes- 
tine into  the  stomach  is  likewise  suggestive  of  a  relaxed  pyloric 
orifice.  The  diagnosis  is  easily  made  by  means  of  the  Roentgen  ray. 
The  degree  of  insufficiency  is  ascertained  by  the  administration  of 
the  Ewald-Boas  test  breakfast  (see  page  96). 

Treatment. — The  treatment  of  pyloric  insufficiency  depends 
upon  the  cause  of  the  disease.  The  clinician  should  endeavor  to 
ascertain  if  there  is  any  gastric  secretion,  and  how  soon  after  the 
ingestion  of  food  the  stomach  becomes  empty.  The  stomach  con- 
tents should  be  aspirated  one  hour  after  the  test  meal  is  taken. 
If  nothing  be  forthcoming,  the  test  meal  should  be  repeated  and 
the  stomach  tube  used  at  quarter-hour  intervals  after  the  meal. 
By  this  means  it  is  possible  to  ascertain  the  quantity  of  gastric 
contents  present  at  any  time.  The  drugs  indicated  in  this  disease 
are  such  as  aid  intestinal  digestion,  since  derangement  of  intes- 
tinal digestion,  accompanied  by  distressing  symptoms,  is  apt  to 
arise  from  the  premature  passage  of  the  food  into  the  duodenum. 
The  combinations  of  sodium  and  magnesium,  rhubarb,  ammonium 
chlorid,  pancreatin,  and  bile  in  the  form  of  inspissated  ox-gall, 
are  all  useful.  In  diarrhea  associated  with  this  condition,  strych- 
nin has  been  found  to  give  the  best  results.  This  drug  should  be 
rapidly  pushed  to  the  point  of  effectiveness.  Many  cases  of  diarrhea 
which  have  persisted  for  years  have  been  known  to  respond  most 
satisfactorily  to  the  administration  of  strychnin  sulphate  in  doses 
of  3  to  10  milligrams  (^  to  \  grain).  The  stools  at  once  diminish 
in  number  and  gain  in  consistency.  Strychnin  has  been  known 
to  produce  excellent  results  in  about  three  and  a  half  weeks  in 
diarrhea  resulting  from  insufficiency  of  the  pylorus  (see  page  677). 


408  MOTOR  NEUROSES 

SINGULTUS  GASTRICUS. 

Hiccough  is  a  symptom  manifested  as  a  noise  made  by  the  sudden 
and  involuntary  contraction  of  the  diaphragm  and  the  simultaneous 
contraction  of  the  glottis  which  arrests  the  rising  air  in  the  trachea. 
Singultus  may  last  for  a  few  minutes  or  much  longer,  or  it  may 
recur  for  d,ays  or  months.  It  is  a  symptom  often  found  in  diseases 
of  the  abdominal  viscera,  such  as  gastritis,  motor  insufficiency 
of  the  first  and  second  degrees,  gastric  carcinoma,  enteritis,  intes- 
tinal obstruction,  appendicitis,  cholera,  pancreatitis  (suppurative), 
diseases  of  the  liver,  and  peritonitis;  it  has  also  been  observed  in 
the  course  of  such  diseases  of  the  nervous  system  as  epilepsy,  tumor 
of  the  brain,  meningitis,  hydrocephalus,  and  hysteria. 

In  rare  cases  of  singultus  gastricus  a  continuous  hiccough  lasting 
for  a  long  time,  varying  from  weeks  to  months,  and  without  regur- 
gitation of  food,  may  be  present;  there  is  usually,  however,  a  hyper- 
esthesia of  the  glandular  layer  of  the  stomach.  Well  nourished 
young  adults,  mostly  young  women,  are  the  commonest  victims 
of  singultus.  Occasionally  it  is  a  prominent  symptom  of  gall- 
bladder disease  and  may  be  so  incessant  as  to  cause  alarming 
exhaustion. 

Treatment. — The  treatment  of  the  underlying  cause  is  of  great 
importance.  For  the  symptom  itself,  citric  acid  and  sodium 
bicarbonate,  one  teaspoonful  of  each,  may  be  given  separately;  the 
resulting  carbon  dioxid  distends  the  stomach  so  that  it  exerts 
pressure  upon  the  diaphragm,  relieving  the  spasm.  Again,  the 
patient  assuming  the  dorsal  decubitus,  both  thighs  and  knees  flexed 
against  the  abdomen  at  the  sharpest  possible  angle  and  pressed 
upward  with  force  for  a  sufficiently  long  time,  will  cause  the  intestine 
to  press  against  the  diaphragm;  the  object  is  to  remove  the  localized 
spasm  by  extension  of  the  contracted  muscle.  Continued  energetic 
pressure  along  the  entire  vertebral  column  frequently  gives  relief. 
External  applications,  such  as  a  mustard  plaster  applied  to  the 
epigastrium,  or  a  mustard  paper  to  the  back  of  the  neck,  are  of 
great  benefit.  An  enema  containing  turpentine  will  remove  the 
gaseous  distention  of  the  abdomen.  When  the  nervous  element 
predominates,  spirits  of  camphor  or  compound  spirits  of  ether  are 
advantageous.  Chloral  in  doses  of  1  Gm.  (15  grains),  repeated 
every  two  hours,  controls  the  convulsive  action  of  the  muscles. 
Spasmodic  irritability  can  be  relieved  by  gelsemium,  which  depresses 
the  respiratory  center  by  diminishing  the  hypersensitiveness  of 
the  nerve  centers;  the  fluid  extract  may  be  given  in  doses  of  0.1 
to  0.2  Cc.  (2  to  3  minims),  to  be  repeated  every  three  or  four  hours. 
Quick  relief  is  often  brought  about  by  0.7  to  1.3  Gm.  (10  to  20  grains) 
of  chloretone.  Ten  drops  of  a  saturated  alcoholic  solution  of 
menthol  in  a  little  water,  repeated  every  hour  if  necessary,  may 
give  relief.     Some  authors  advise  oil  of  amber  in  the  dose  of  1  Cc. 


SINGULTUS  GASTRICUS  409 

(15  drops)  every  two  hours.  Ten-drop  doses  of  1:1000  solution 
of  epinephrin  repeated  in  an  hour  will  often  prove  efficacious.    It 

may  be  necessary  to  cheek  the  spasmodic  contraction  of  the  dia- 
phragm by  inducing  partial  or  complete  general  anesthesia.  In 
some  cases  a  hypodermic  of  morphin  and  atropin  may  be  necessary. 
Continuous  traction  of  the  tongue  will  often  bring  quick  relief.  The 
hiccough  can  frequently  be  stopped  by  compressing  the  eyeballs  as 
for  the  oculocardiac  reflex  (see  page  390).  This  compression  slows 
the  pulse  and  induces  sleep;  it  should  be  frequently  repeated. 
The  accompanying  constipation  should  always  have  attention,  and 
its  cause  must  be  determined.  This  is  essential,  as  hiccough  may 
be  brought  about  by  intestinal  toxemia. 

Recently  benzyl  benzoate  has  been  found  to  be  a  useful  remedy 
for  hiccough.  A  20-per-cent.  solution  in  alcohol  is  prescribed,  and 
of  this  thirty  drops  in  water  or  milk  every  four  hours.  Benzyl 
benzoate  is  also  of  diagnostic  interest  in  differentiating  between 
hiccoughs  of  purely  central  origin  and  those  which  are  due  to  some 
peripheral  disturbance.  Inasmuch  as  benzyl  benzoate  exerts  its 
chief  effect  peripherally  on  the  smooth  muscle  structures,  it  is  most 
useful  in  the  treatment  of  hiccoughs  of  peripheral  origin  (see  page 
276). 


CHAPTER  XVIII. 

SENSORY  NEUROSES. 

Gastralgia;  Hyperesthesia:  Gastralgokenosis;  Nausea; 
Bulimia;  Akoria;  Anorexia. 

GASTRALGIA. 

Gastralgia,  known  also  as  cardialgia,  gastrodynia,  and  neuralgia 
of  the  stomach,  is  a  condition  peculiar  to  individuals  of  a  nervous 
temperament.  The  diagnosis  cannot  be  confirmed  until  a  careful 
exclusion  is  made  of  organic  diseases  of  the  stomach.  The  pains 
complained  of  in  gastralgia  are  due  to  morbid  or  irritating  conditions 
of  the  sympathetic  nerve  ganglia  located  in  front  of  the  spinal 
column.  The  site  of  the  pain  is  the  epigastric  distribution  of  the 
lumbar  sympathetic.  The  celiac  plexus,  the  superior  mesenteric 
plexus  and  the  aortic  plexus  may  also  be  involved.  The  location 
of  the  pain  is  in  reality  exterior  to  the  stomach.  The  nervous 
gastric  pains  occur  periodically  and  spasmodically,  and  at  times 
become  so  intense  as  to  be  unbearable.  The  attacks  last  from  a  few 
hours  to  several  days;  the  pains  radiate  toward  the  back  and  also 
up  into  the  chest;  they  are  usually  independent  of  the  reception  of 
food.  Nervous  excitement  is  apt  to  bring  on  the  attacks,  during 
which  vomiting  rarely  takes  places.  Eructations  are  common.  The 
celiac  plexus  is  often  markedly  sensitive  to  pressure  exerted  in  the 
median  line  of  the  epigastric  region.  The  superior  mesenteric 
plexus,  as  well  as  the  aortic,  occasionally  becomes  very  sensitive, 
as  shown  by  pressure  on  two  points  situated  immediately  above  and 
below  the  umbilicus.  There  is  often  found  a  hyperesthetic  zone 
in  the  epigastrium.  The  differential  diagnosis  between  gastralgia 
and  ulcer  of  the  stomach  is  fraught  with  difficulty,  and  established 
only  after  careful  consideration  of  the  symptoms  of  ulcer,  such  as 
pressure  points,  relation  of  the  pains  to  the  reception  of  food,  and 
occult  hemorrhage.  In  ulcer  the  hyperesthetic  cutaneous  zone  is 
usually  smaller  in  area  than  in  gastralgia.  Among  the  recognized 
causes  of  gastralgia  are  syphilis,  gallstones,  and  chronic  appendicitis; 
the  pain  is  reflex,  through  the  sympathetic  system. 

Treatment. — The  treatment  of  gastralgia  should  be  directed 
toward  the  generally  debilitated  condition  of  the  patient,  and 
should  embrace,  among  other  things,  hydrotherapy,  change  of 
climate,  and  the  milk  cure.  Very  little  or  no  restriction  need  be 
made  in  regard  to  diet,  since  the  condition  is  purely  extragastric.     It 


y 


GASTRALGIA  411 

is  not  necessary  that  patients  should  be  kept  on  either  fluid  or  light 
diet.  The  regimen  may  be  varied  and  generous  in  quantity  without 
aggravating  in  any  way  the  painful  symptoms.  The  diet,  however, 
should  be  suited  to  the  individual  case.  It  will  be  necessary  in 
many  cases  of  this  class  to  persuade  patients  to  eat,  and  to  impress 
upon  them  that  there  is  no  connection  between  the  ingestion  of 
food  and  the  pains  of  which  they  complain,  but  that  there  is  danger 
of  aggravating  the  symptoms  by  abstaining  from  food. 

During  the  acute  attack  the  patient  should  be  put  to  bed  and 
hot  compresses  or  poultices  should  be  applied  to  the  region  of  the 
stomach.  Good  results  are  obtained  by  a  "half-bath"  or  a  pro- 
tracted hot  sitz  bath  (see  Chapter  XII) .  When  the  pains  are  of  a 
violent  nature,  resort  must  be  had  to  such  drugs  as  morphin  or 
opium  and  belladonna  in  combination.. 


]$ — Morphinse  sulphatis  0 

Extracti  belladonna?  .  .  .  .  0 
Olei  theobromatis 2 

Misce  et  ft.  suppos.  no.  i. 

Sig. — As  required  for  the  relief  of  pain. 


Gm.  or  Cc. 

01  gr. 


02  gr.  f 

0  gr.  xxx 


Gm.  or  Cc. 

jfy — Extracti  opii 0|05  gr.  f 

Extracti  belladonna?      ....       0 1 02  gr.  § 

Olei  theobromatis 2 1 0  gr.  xxx 

Misce  et  ft.  suppos.  no.  i. 

Sig. — As  required  for  the  relief  of  pain. 


5  gr.  viiss 

0  5j 

0  gtiss 

0  §iss 


Gm.  or  Cc. 
1$ — Cocainae  hydrochloridi        ...       0 

Aquse  aurantii 30 

Aqua?  chloroformi 75 

Aquse  destillata? 45 

Misce. 

Sig. — One  to  three  teaspoonfuls  in  water  at  the  beginning  of  the  attack. 

In  severe  cases  morphin  should  be  given  hypodermically  at 
once.  Among  the  medicaments  which  may  be  administered  by 
mouth  are  cocain  (0.05  Gm.  to  150  Cc.  of  water,  in  teaspoonful 
doses),  codein  phosphate  (0.03  to  0.05  Gm. — |  to  1  grain),  chloral 
hydrate,  antipyrin  (0.5  Gm.),  acetylsalicylic  acid  (1  Gm.),  chloro- 
form water,  validol,  and  the  ammoniated  tincture  of  valerian. 
Extract  of  cannabis  indica  has  also  been  recommended  for  relief 
of  the  pains. 

Gm.  or  Cc. 

1^ — Extracti  cannabis  indica?   ...       0 1 03  gr.  ss 

Sacchari  albi 0 1 50  gr.  viij 

Misce  et  ft.  pulv.  no.  i. 
Sig. — One  every  four  hours. 

Gm.  or  Cc. 
1^ — Tinctura?  cannabis  indica?        .  4|0  3j 

Tinctura?  Valeriana?       ....        6|0  5iss 

Misce. 
Sig. — Twenty  drops  to  be  taken  at  a  dose. 


412  SENSORY  NEUROSES 

Hoffman's  anodyne,  20  to  30  drops  on  a  lump  of  sugar,  is  valu- 
able in  the  treatment  of  this  condition.  Hot  drinks  such  as  pepper- 
mint tea  or  valerian  tea  are  productive  of  favorable  results.  If  con- 
venient, galvanization  is  worthy  of  a  trial,  when  the  anode  should 
be  placed  over  the  epigastrium  and  the  cathode  over  the  spinal 
column  for  five  to  ten  minutes.  The  faradic  current  may  also 
be  used.  In  cases  where  pains  are  less  violent  but  of  prolonged 
duration,  massage  and  electricity  are  indicated  in  addition  to  warm 
applications. 

A  special  form  of  gastralgia  is  represented  by  the  gastric  crises 
of  locomotor  ataxia,  which  are  characterized  by  violent  cramps  in 
the  stomach  and  pains  in  the  back,  followed  by  vomiting.  As  to 
the  nature  of  these  crises  we  are  still  in  the  dark,  nor  have  we  by 
any  means  been  able  to  cut  short  the  attacks  except  by  the  use  of 
morphin  or  the  injection  of  cocain  to  anesthetize  the  posterior 
roots.  It  is  an  advantage  to  distinguish  between  vagus  and  sympa- 
thetic gastric  crises.  The  vagus  is  involved  when  there  is  pain, 
vomiting,  tachycardia,  and  disturbance  of  the  larynx.  Sympathetic 
crises  are  more  frequent.  Konig  recommends  injecting  100  Cc. 
(3  ounces)  of  a  0.5-per-cent.  solution  of  novocain  into  the  muscles 
of  the  back  on  a  line  each  side  of  the  spinous  processes.  Alcohol  can 
be  injected  in  the  sameway;  the  results  are  similar  to  those  obtained 
by  its  use  in  the  treatment  of  facial  neuralgia.  The  following  drugs 
are  recommended  in  addition  to  the  measures  already  mentioned  in 
connection  with  the  treatment  of  the  acute  painful  seizures :  Anti- 
pyrin  0.6  Gm.  (10  grains),  or  cerium  oxalate  0.3  to  0.6  Gm.  (5  to  10 
grains),  three  times  a  day;  acetylsalicylic  acid  and  the  salicylates. 

]$- — Sodii  salicylate 

Caffeinse  sodiosalicylatis     . 

Aquse q.  s.  ad 

Misce. 

Sig. — 1  to  2  Cc.  (15  to  30  minims)  of  the  sterilized  solution  to  be  injected 
daily  into  the  median  vein.     (Von  Mendel.) 

In  the  operation  of  rhizotomy  Foerster  says  the  aim  is  to  resect 
'  the  sensory  gastro-intestinal  fibers  of  the  sympathetic  nerve,  and 
this  may  require  resection  of  the  roots  from  the  twelfth  to  the  fifth 
dorsal  or  even  higher.  It  may  be  possible  to  determine  beforehand 
exactly  the  roots  requiring  resection,  by  careful  study  of  the  loca- 
tion of  the  pains  and  of  the  superficial  hyperesthetic  zones.  There 
is  always  a  possibility  that  the  crises  may  be  due  to  the  vagus  or 
to  direct  irritation  of  the  vomiting  center  in  the  medulla  oblongata, 
in  which  case  rhizotomy  of  course  would  not  relieve.  If  the  blood 
supply  of  the  spinal  cord  is  interfered  with,  paralysis  may  result. 
Many  of  the  patients  after  the  operation  of  rhizotomy  have  been 
restored  to  comparative  health  and  enabled  to  return  to  business. 
Franke's  operation  has  been  employed  with  good  effect  in  the 


Gm.  or  Cc. 

810 

2  0 
50  0 

oij 
gr.  xxx 

GASTRIC  II YPERESTIIESIA  U3 

treatment  of  tabetic  gastric  crises.  The  aim  is  to  pull  out  the 
intercostal  nerves  and  thus  realize  by  a  comparatively  simple 
technic  results  equivalent  to  those  of  resection  of  the  posterior 
spinal  nerve  roots,  namely,  interrupting  the  continuity  of  the  fibers 
of  the  sympathetic  nerve  innervating  the  seat  of  the  pains.  The 
reflex  arcs  have  also  been  broken  by  severing  the  vagus.  Vagotomy 
(resection  of  the  vagus)  frequently  frees  the  patient  from  gastric 
crises  (see  page  783). 

The  majority  of  gastralgias  are  secondary  affections  and  may 
occur  in  the  course  of  almost  any  affection  of  the  stomach,  intes- 
tine or  other  abdominal  organ,  in  arteriosclerosis,  toxemias,  anemia, 
and  diseases  of  the  male  and  female  sexual  organs.  In  all  such 
cases  treatment  should  be  directed  toward  the  primary  cause. 

GASTRIC  HYPERESTHESIA. 

Gastric  hyperesthesia  is  defined  as  an  increased  sensitiveness  of 
the  gastric  mucous  membrane  to  chemical,  mechanical  and  thermic 
stimuli,  or  to  any  one  of  these.  A  patient  with  a  good  appetite 
may  suffer  pain  when  certain  articles  of  food  or  drink  are  taken, 
which  is  not  relieved  until  the  food  or  drink  has  disappeared  from 
the  stomach.  The  stomach  is  often  hypersensitive  to  sugar,  fat, 
and  carbohydrates.  Of  thermic  stimuli  the  stomach  is  more  sen- 
sitive to  cold  than  to  heat.  The  abnormal  sensations  may  vary, 
amounting  in  some  cases  to  severe  pain  and  vomiting.  During 
digestion  there  may  be  sensations  of  fulness,  pressure,  tension,  or 
burning,  but  these  usually  cease  with  the  evacuation  of  the  stomach. 
Gastric  hyperesthesia  is  a  condition  rather  frequent  in  neurasthenic 
and  hysterical  subjects.  Patients  come  to  associate  the  distressful 
symptoms  with  the  ingestion  of  food,  and  as  a  result  the  quantity 
of  food  consumed  becomes  less  and  less  and  the  patient  loses  flesh 
and  strength. 

Treatment. — The  treatment  should  be  directed  against  the  cause. 
Efforts  should  be  made  to  improve  the  general  nutrition,  and,  if 
necessary,  a  course  of  hyperalimentation  (see  page  569)  should  be 
instituted.  Asthenic  patients  require  rest  in  bed,  and  should  be 
kept  absolutely  quiet  both  mentally  and  physically.  The  dietetic 
cure  should  be  commenced  with  caution;  it  should  consist  at  first 
of  milk  and  kefir,  to  be  gradually  changed  to  a  diet  of  semisolid 
consistency.  The  dietary  should  be  such  as  to  reaccustom  the 
patient  to  ordinary  food.  When  the  distaste  for  food  is  very  marked 
it  may  be  necessary,  at  times,  to  resort  to  nutrient  enemata  (see 
page  243). 

Nitrate  of  silver  is  particularly  effective  in  diminishing  the 
sensitive  condition  of  the  stomach.  A  tablespoonful  of  a  solution 
of  0.2  to  0.3  Gm.  (3  to  5  grains)  to  100  Cc.  (giiiss)  of  water  is 
given  three  times  a  day.     It  is  best  administered  as  a  tablespoonful 


414  SENSORY  NEUROSES 

of  the  solution  to  a  wineglass  of  distilled  water,  before  breakfast,  and 
half  an  hour  before  dinner  and  supper.  Lavage  with  silver  nitrate 
solution  (1:10,000)  also  acts  well.  "When  there  is  much  pain, 
belladonna,  chloroform  or  a  preparation  of  A'alerian  is  indicated. 
Anesthesin  may  be  given  in  doses  of  0.25  to  0.5  Gm.  (4  to  7|  grains), 
ten  to  fifteen  minutes  before  meals.  For  the  relief  of  gastric  irrita- 
tion Rochester  advises  the  following  combination : 


Gm.  or  Cc. 

1^ — Strontii  bromidi 6 

Sodii  bicarbonatis 40 

Carbonis  ligni 20 

Bismuthi  subcarbonatis      ...  20 

Magnesia? 180 

Misce. 

Sig. — Two  teaspoonfuls  in  water  three  times  a  day,  after  meals. 


0  5iss 

0  3x 

o  5v 

0  3v 

0  gvj 


If  between  meals  patients  are  troubled  with  burning  or  pain  in 
the  stomach  which  may  be  accounted  for  by  the  presence  of  hyper- 
acidity, Stockton's  sedatives  will  be  found  satisfactory. 

When  the  gastric  distress  is  severe  and  hyperacidity  exists : 

Gm.  or  Cc. 

B — Cerii  oxalatis 1 J  0  gr.  xv 

Bismuthi  subcarbonatis      ...        20  5ss 

Magnesii  carbonatis      ....        4|0  5j 

Misce. 

Sig. — A  teaspoonful  stirred  into  one-half  glass  of  water.  (Stockton.) 

When  the  action  of  the  magnesia  is  too  laxative,  and  for  this 
reason  we  desire  a  gastric  sedative  that  will  quiet  the  bowels : 

Gm.  or  Cc. 

B — Cerii  oxalatis      ......        1 10  gr.  xv 

Bismuthi  subcarbonatis      ...        40  3j 

Cretan  prseparatse 4  0  5j 

Carbonis  ligni 2 [0  3ss 

Misce. 

Sig. — Teaspoonful  well  stirred  into  one-half  glass  of  water.     (Stockton.) 

GASTRALGOKENOSIS. 

The  term  "  gastralgokenosis"  is  used  to  designate  stomach-ache 
or  the  sensation  of  painful  pressure  in  the  region  of  the  stomach 
when  that  viscus  is  empty.  In  this  condition  there  is  hyperesthesia 
of  the  empty  stomach.  The  pain  may  become  very  severe  a  few 
hours  after  eating,  when  the  stomach  is  empty.  Excess  of  hunger 
has  never  been  observed  to  accompany  this  condition,  though  pain 
is  promptly  relieved  by  the  ingestion  of  food.  Duodenal  ulcer 
must  be  differentiated  (see  Chapter  XLI) . 

The  patient  should  endeavor  to  ward  off  the  attack  by  never 
permitting  the  stomach  to  become  quite  empty.  He  should  have 
with  him  always  some  articles  of  food,  such  as  crackers  or  milk. 
Small  doses  of  extract  of  opium,  0.006  to  0.008  Gm.  (^  to  |  grain), 
and  the  bromids,  are  indicated  for  this  condition. 


BULIMIA  415 


NERVOUS  NAUSEA. 


Idiopathic  nausea  appears  most  frequently  in  women  and  in 
consequence  of  a  general  neurotic  condition,  anemia  and  chlorosis, 
or  disturbance  of  the  menstrual  function.  Purely  functional 
nausea  may  occur  at  intervals.  Mental  disturbance  acts  as  an 
exciting  cause.  Nervous  nausea  may  occur  in  the  morning  while 
the  stomach  is  empty  after  the  night's  fast.  During  the  attack, 
patients  experience  a  pronounced  aversion  to  food.  The  disease 
may  at  times  assume  an  obstinate  form,  which  may  be  due  to  the 
variable  condition  of  the  blood  supply  to  the  brain.  The  gastric 
functions,  in  the  majority  of  cases,  are  normal;  rarely  a  moderate 
degree  of  hyperacidity  may  be  present. 

Treatment. — When  the  nausea  is  due  to  neurasthenia  or  anemia, 
these  conditions  should  receive  attention.  Anemia  may  be 
remedied;  that  is,  hemoglobin  can  be  rapidly  increased  by  the 
hypodermic  use  of  the  citrate  of  iron,  as  described  on  page  581. 
Sometimes  the  hyperalimentation  cure  should  be  instituted  in 
cases  where  the  general  nutrition  is  low.  Patients  occasionally 
do  well  when  removed  from  their  homes  and  customary  surround- 
ings. Particular  attention  should  be  paid  to  the  mental  state  of 
the  patient,  which  is  often  depressed.  Severe  cases  should  be 
treated  in  a  properly  conducted  hospital  or  a  sanitarium.  Food 
should  be  served  in  an  attractive  manner,  for  the  sake  of  its  appe- 
tizing influence  and  the  pleasure  which  details  of  this  kind  give 
the  patient.  Should  there  be  nausea  early  in  the  morning,  it  will 
be  well  to  serve  breakfast  in  bed.  Hydrotherapeutics  will  be 
found  a  valuable  factor  in  the  treatment.  For  cutting  short  the 
attack  of  nausea,  a  bath  at  64°  F.  or  a  cold  douche  is  recommended. 
Both  intraventricular  and  extraventricular  galvanization  may  be 
employed.  The  bromids,  chloral  (3  to  5  grains  three  or  four  times 
daily),  and  validol  (six  to  eight  drops  every  two  or  three  hours) 
are  indicated  in  the  treatment  of  nervous  nausea. 

BULIMIA. 

Bulimia,  cynorexia,  and  hyperorexia  are  terms  used  to  designate 
a  condition  in  which  the  sensation  of  hunger  is  more  frequent 
and  more  intense  than  in  the  normal  state.  Bulimia  may  be  a 
primary  affection,  or  it  may  be  associated  with  other  diseases,  as 
gastric  ulcer  or  carcinoma,  hyperacidity,  pancreatic  affections, 
exophthalmic  goiter,  hysteria  or  neurasthenia;  and  the  condition 
may  be  either  acute  or  chronic.  "In  the  midst  of  perfect  euphoria, 
a  feeling  of  intense  hunger  overcomes  the  patient,  with  a  desire  to 
satisfy  it.  This  hunger  sensation  is  associated  with  a  gnawing 
feeling  in  the  stomach,  and  the  utmost  fear  and  anxiety,  as  if 
something  alarming  were  going  to  happen.     If  the  feeling  of  hunger 


416  SENSORY  NEUROSES 

is  not  satisfied  very  quickly,  severe  headache  and  trembling  of 
the  body,  or  even  fainting  spells,  may  occur."  (Einhorn.)  The 
attack  of  bulimia  sometimes  yields  to  the  ingestion  of  a  small 
amount  of  food,  but  as  a  rule  large  quantities  have  to  be  taken. 

Treatment. — The  cause  should  be  carefully  ascertained.  Simple 
articles  of  food  or  drink,  such  as  crackers,  zwieback,  chocolate,  or 
milk,  should  be  carried  by  those  who  are  subject  to  these  attacks, 
or  be  at  all  times  within  convenient  reach. 

Efforts  have  been  made  to  influence  the  irritable  condition  of 
the  "hunger  center"  by  the  use  of  drugs.  Bromids  in  large  doses, 
1.5  to  2  Gm.  (25  to  30  grains),  may  be  given  two  or  three  times 
daily.     Opium  with  belladonna  can  be  given,  as  follows : 

Gm.  or  Cc. 
1$ — Extracti  opii, 

Extracti  belladonnae    ...       aa      0 1 01  gr.  £ 

Misce  et  ft.  caps.  no.  i. 
Sig. — One  capsule  to  be  taken  morning  and  night. 

Arsenous  acid,  0.001  Gm.  (^  grain),  in  pill  form,  or  liquor  potassi 
arsenitis,  may  be  administered.  Cocain  may  be  prescribed  in 
the  following  form : 

Gm.  or  Cc. 

1$ — Cocainae  hydrochloride       ...         Oil  gr.  iss 

Aquae  amygdalae  amarse     .      .      .        10  [0  5iiss 

Misce. 
Sig. — Ten  drops  several  times  a  day. 


Or: 


Gm.  or  Cc. 


1$ — Ammonii  bromidi, 

Sodii  bromidi aa        8 1 0  3JJ 

Aquae  menthae  piperitae      ...       60 10  Sij 

Misce. 

Sig. — One  teaspoonful  twice  daily. 

AKORIA. 

In  patients  suffering  from  akoria  the  normal  sensation  of  satiety 
is  lacking,  even  after  a  full  meal.  Patients  do  not  know  when  they 
have  eaten  enough.  There  may  be  no  particular  desire  for  food, 
however,  and  even  well-marked  anorexia  may  be  present.  Akoria 
is  found  in  connection  with  such  conditions  as  give  rise  to  bulimia 
or  polyphagia.  Neurasthenic  and  hysteric  subjects  are  among  its 
victims.  The  treatment  should  consist  of  change  of  climate,  hyper- 
alimentation, hydrotherapy,  electricity,  and  psychotherapeutics. 

NERVOUS  ANOREXIA. 

Nervous  anorexia  is  a  term  used  to  designate  loss  of  appetite 
of  a  pronounced  and  chronic  nature.  There  exists  on  the  part 
of  the  patient  a  repugnance  to  every  kind  of  food.     In  spite  of  this 


NERVOUS  ANOREXIA  417 

fact,  the  functioning  powers  of  the  stomach  and  intestine  are, 
as  a  rule,  normal.  The  disease  is  apparently  characterized  by 
anesthesia  of  the  hunger  "nerves."  Nervous  anorexia  is  always 
a  symptom  of  such  general  nervous  conditions  as  neurasthenia, 
sexual  neurasthenia,  and  hysteria.  It  may  result  seriously,  from 
lack  of  proper  nourishment  to  the  body.  Among  the  exciting 
causes  are  frequently  found  great  mental  depression,  worry,  anxiety, 
and  fright. 

Treatment.- — This  consists  in  maintaining  the  nutrition,  if  need 
be,  by  means  of  the  so-called  food  or  hyperalimentation  cures. 
Removal  of  the  patient  from  his  home  surroundings  must  be  con- 
sidered in  grave  cases.  Sometimes  it  is  necessary  to  resort  to  nutri- 
ent enemata  or  to  gavage.  In  gavage,  or  feeding  by  the  stom- 
ach tube,  such  nourishment  as  milk,  eggs,  gruel  or  artificial  food  is 
poured  into  the  stomach  through  a  funnel  that  fits  into  the  external 
end  of  the  tube.  Care  must  be  exercised  not  to  cause  too  much 
distention  of  the  stomach,  unaccustomed  to  food  in  even  ordinary 
quantities,  until  tolerance  has  been  established. 

Stomachics,  such  as  orexin,  0.3  Gm.  (5  grains),  three  times  a 
day,  two  hours  before  meals,  and  cinchona  bark  preparations,  are 
indicated. 

Gm.  or  Cc. 

]$ — Decocti  cinchonse 10-180 JO  3iiss-5vj 

Acidi  sulphurici  diluti  0 !  3  TTlv 

Syrupi  zingiberis    .      .      q.  s.  ad  200 10  Bvij 

Misce. 

Sig. — One  tablespoonful  three  times  a  day,  half  an  hour  before  meals. 

Gm.  or  Cc. 

1$ — Fluidextracti  cinchonae     ....     6010  oij 

Sig. — One-half  teaspoonful  in  a  wineglass  of  water,  to  be  taken  three  times 
a  day  (before  meals) . 

The  stomach  may  also  be  washed  out  with  water  in  which 
stomachics  have  been  incorporated.  Arsenic,  iron,  small  doses  of 
the  bromids,  and  strychnin  (0.001  to  0.002  Gm.,  ^  to  ^  grain) 
may  be  prescribed  as  occasion  requires. 


27 


CHAPTER  XIX. 
NERVOUS  DYSPEPSIA— NEURASTHENIA  GASTRICA. 

Von  Leube,  who  first  described  the  condition  designated  nervous 
dyspepsia,  included  those  subjective  nervous  symptoms  which  are, 
as  a  rule,  of  marked  intensity,  and  for  which  it  was  impossible 
to  find  cause  in  any  of  the  organic  or  functional  disturbances  of 
the  stomach.  Later,  however,  it  was  discovered  that  nervous 
symptoms  of  a  like  nature  present  themselves  in  disturbances  of 
the  sensory,  secretory,  and  motor  functions  of  the  stomach.  As  a 
consequence  the  term  nervous  dyspepsia  as  now  employed  signifies 
a  gastric  neurosis  which  is  entirely  independent  of  organic  dis- 
turbances, being  of  purely  nervous  origin,  although  there  may  be 
coincident  disturbances  of  the  motor,  sensory,  or  secretory  functions. 

Etiology. — The  cause  of  nervous  dyspepsia  must  be  sought  in 
the  increased  irritability  of  the  autonomic  nervous  system.  This 
heightened  irritability,  however,  shows  itself  but  rarely  as  an 
independent  affection.  The  class  of  persons  apt  to  be  sufferers 
from  this  condition  are  possessed  of  a  more  or  less  irritable  and 
unstable  central  nervous  system.  They  are  spoken  of  as  being  of 
a  nervous  disposition.  In  such  persons  fright,  sorrow,  care,  patho- 
phobia, or  other  emotion,  often  acts  as  an  exciting  cause  of  actual 
dyspeptic  conditions. 

Gastric  Neuroses  and  Eye-strain. — The  medical  profession  is 
indebted  to  Dr.  George  M.  Gould  for  the  persistency  with  which 
he  has  maintained  that  many  of  the  so-called  gastric  neuroses  are 
due  to  eye-strain.  Nervous  dyspepsia  resulting  from  eye-strain 
is  characterized  by  such  symptoms  as  sick  headache,  anorexia, 
anemia,  and  many  types  of  malnutrition,  all  of  which  may  be  due 
to  astigmatism  or  anisometropia.  The  influence  of  the  visual 
organs  over  the  digestive  system  may  be  proved  by  the  fact  that 
a  normal  person  wearing  glasses  that  may  be  worn  with  comfort 
by  another  becomes  nauseated,  even  to  the  point  of  vomiting. 
There  is  no  truth  in  medical  science  more  susceptible  of  demon- 
stration and  more  persistently  ignored  in  daily  practice  than  the 
immediate  association  of  eye-strain  and  malassimilation.  Head- 
aches of  all  kinds,  sick  headaches,  migraine,  hemicrania,  "rush  of 
blood  to  the  head,"  are  usually  due  to  eye-strain.  My  personal 
experience  confirms  the  belief  that  eye-strain  is  frequently  the  main 
etiologic  factor  in  nervous  dyspepsia,  since  beneficial  results  are 
obtained  as  soon  as  the  errors  of  refraction  are  properly  corrected. 


SYMPTOMS  419 

Cholecystitis,  cholelithiasis,  appendicitis,  constipation,  enteroptosis, 

or  helminthiasis  may  induce  nervous  dyspepsia,  probably  by  trans- 
mission of  the  irritation  of  the  intestinal  sympathetic  nerves  to 
the  nerves  of  the  stomach.  Epigastric  hernia  is  frequently  a  cause 
of  this  neurosis;  as  are  also  diseases  of  the  female  reproductive 
organs,  such  as  salpingitis,  lacerated  cervix,  lacerated  perineum,  and 
anomalies  of  menstruation.  During  the  menstrual  period  the  gastric 
secretion  is  often  hyperacid.  In  the  male,  sexual  excesses  are  not 
infrequently  responsible  for  nervous  dyspepsia.  Hemorrhoids  are 
a  very  common  cause.  Among  the  etiologic  factors  must  also  be 
mentioned  diseases  of  such  remote  organs  as  the  lungs,  heart,  and 
kidneys. 

It  has  long  been  recognized  that  patients  who  for  years  had  been 
treated  for  nervous  dyspepsia  have  been  cured  after  an  acute  attack 
of  appendicitis  which  necessitated  operation.  The  condition  of  the 
appendix  had  not  been  considered  in  connection  with  the  treatment 
as  the  cause  of  the  nervous  dyspepsia.  Unsuspected  gallstones 
may  often  produce  symptoms  of  nervous  dyspepsia.  A  sudden 
attack  of  gallstone  colic  draws  our  attention  to  the  gall  bladder; 
and  after  removal  of  the  offending  gallstones  the  gastric  symptoms 
entirely  disappear. 

There  is  a  vast  amount  of  suffering,  manifested  by  general  ill 
health,  vague  stomach  and  intestinal  symptoms,  progressive  loss 
of  flesh  and  strength,  obscure  nervous  conditions,  anemia,  and 
obstinate  constipation,  occasioned  by  chronic  appendicular  inflam- 
mation. The  pathologic  condition  in  these  cases  is  often  due  to 
a  slow  proliferation  of  connective  tissue  in  the  walls  of  the  appendix. 
There  is  no  pus  formation,  and  it  may  be  months  or  years  before 
an  attack  of  acute  appendicitis  occurs  to  clear  up  the  diagnosis. 
When  pain  is  felt  in  these  cases,  it  is  often  not  in  the  region  of  the 
appendix,  over  the  McBurney  point;  it  may  be  more  generalized 
about  the  umbilicus  or  be  referred  to  the  site  of  the  gall  bladder  or 
be  felt  in  the  stomach.  These  referred  pains  are  not  surprising 
when  we  remember  the  abundant  connections  of  the  rich  nerve 
supply  of  the  appendix,  through  the  superior  mesenteric  plexus  of 
the  sympathetic,  with  the  pneumogastric,  hepatic,  and  gastric 
plexuses.  These  cases  are  diagnosticated  as  nervous  dyspepsia 
and  are  treated  expectantly  and  symptomatically;  when  the  phy- 
sician has  exhausted  his  patience  and  resources  he  classes  them 
among  neurasthenics,  and  is  likely  to  send  them  on  a  sea  voyage, 
to  a  mineral  spring,  or  to  a  sanatorium.  Many  such  cases  recover 
when  the  appendix  or  the  gallstones  are  removed.  Physicians 
should  be  on  the  alert  for  concealed  appendicitis,  well  named  by 
Ewald  "appendicitis  larvata."  Obscure  as  it  is,  the  true  diagnosis 
will  often  be  reached  only  by  a  process  of  exclusion  (see  page  772). 

Symptoms. — Nervous  dyspepsia  gives  rise  to  a  variety  of  symp- 
toms, some  of  which  are  general  in  character  while  others  are 


420    NERVOUS  DYSPEPSIA— NEURASTHENIA  GASTRIC  A 

referable  particularly  to  the  stomach.  It  is  at  times  a  difficult 
matter  to  differentiate  between  symptoms  of  purely  nervous  origin 
and  those  which  have  an  organic  or  functional  basis.  The  variety 
and  variability  of  the  symptoms,  as  well  as  the  manner  in  which 
the  patient  describes  them,  are  characteristic  of  the  condition 
present.  Often  such  patients  are  free  from  distressing  symptoms 
for  days,  or  even  weeks,  when,  owing  to  some  trivial  cause,  most 
likely  of  a  psychic  nature,  a  recurrence  of  the  symptoms  takes 
place.  The  appetite  of  the  patient  is  apt  to  be  precarious:  coarse 
food  in  large  quantities  may  perhaps  be  partaken  of  without 
aggravation  of  the  symptoms,  while,  on  the  other  hand,  certain 
dietetic  articles  which  might  be  taken  with  impunity  by  a  person 
suffering  from  organic  disease  of  the  stomach  are  rejected  as  "not 
agreeing"  with  the  patient. 

The  general  symptoms  of  which  patients  suffering  from  nervous 
dyspepsia  complain  are:  fulness  of  the  head,  cephalalgia,  migraine, 
inability  to  work,  vertigo,  lassitude,  insomnia,  hypochondriac 
and  melancholic  illusions.  Opposed  to  this  catalogue  of  subjec- 
tive symptoms  the  objective  symptoms  are  often  inconsiderable. 
Patients,  as  a  rule,  exhibit  the  well-known  neurasthenic  type. 
The  condition  of  nutrition  is  usually  good.  When  the  subjective 
symptoms  become  severe,  there  is  at  times  a  diminution  in  weight, 
owing  to  the  refusal  of  the  patient  to  partake  of  adequate  nourish- 
ment. A  condition  of  genuine  inanition  may  develop.  Palpation 
of  the  stomach  often  elicits  hypersensibility  to  pressure  over  the 
celiac  plexus.  Cutaneous  hyperesthesia  is  sometimes  found  over 
the  region  of  the  stomach.  While  all  this  is  present  the  stomach 
may  function  in  a  perfectly  normal  manner.  In  other  cases  hyper- 
acidity, subacidity  or  achylia  may  be  present,  either  singly  or  in 
combination  with  atonic  conditions  of  the  stomach.  It  is  a  pecu- 
liarity of  nervous  dyspepsia  that  well-marked  variability  in  the  secre- 
tory functions  sometimes  exists,  so  that  in  the  same  patient  achylia, 
subacidity,  normal  acidity,  and  hyperacidity  may  be  discovered  at 
different  examinations — heterochylia  (see  page  94). 

The  physician  should  carefully  examine  the  entire  gastrointes- 
tinal tract  in  every  instance  of  suspected  nervous  dyspepsia  in 
order  to  confirm  or  establish  his  diagnosis.  Oftentimes  an  accurate 
diagnosis  is  only  achieved  after  a  prolonged  period  of  observation. 
Prognosis. — The  prognosis  for  a  complete  cure  without  recur- 
rence is  not  favorable.  It  is  possible,  however,  under  proper 
treatment,  to  bring  about  marked  improvement  in  the  condition 
of  the  patient. 

Prophylaxis. — As  prophylaxis,  the  children  of  neurotic  individ- 
uals in  whom  the  habitus  enteroptoticus  is  well  marked  should 
be  kept  well  nourished  and  should  be  given  gymnastic  exercises. 
The  avoidance  of  excessive  mental  exertion  is  an  important  prophy- 
lactic measure. 


TREATMENT  IJ I 

Treatment. — The  treatment  of  nervous  dyspepsia  ]>cr  ae  should 
be  directed  toward  correcting  the  causes,  whatever  they  may  be. 
If  the  nervous  dyspepsia  is  secondary,  the  primary  condition 
should  receive  appropriate  treatment.  The  subjective  symptoms 
of  the  patient  yield  most  readily  when  he  is  removed  from  his 
customary  environment  and  is  accorded  complete  rest  of  both 
body  and  mind.  Marked  benefit  has  resulted  in  some  cases  from 
a  six  weeks  period  of  absolute  rest.  During  the  rest  cure,  so-called, 
the  patient's  mind  should  be  occupied  as  little  as  possible.  The 
relationship  of  the  physician  and  patient  in  such  cases  is  of  the 
utmost  importance.  That  physician  will  have  the  greatest  success, 
other  things  being  equal,  who  knows  how  to  gain  the  confidence 
of  his  patient  and  is  able  to  exert  an  influence  over  him.  Many 
patients,  however,  owing  to  domestic  or  financial  circumstances, 
are  unable  to  leave  their  home  surroundings.  Such  patients  should 
be  instructed  to  lie  down  for  an  hour  or  twro,  regularly,  every  morn- 
ing and  afternoon. 

The  question  of  nutrition  is  of  paramount  importance.  The 
diet  should  be  adapted  to  the  individual  case,  and  greater  latitude 
may  be  permitted  in  regard  to  variety  and  quantity  than  in  cases 
of  organic  gastric  disease,  since  the  dyspeptic  symptoms  are  not 
intimately  comiected  with  the  food  in  the  stomach.  An  effort 
should  be  put  forth  to  maintain  the  nutrition  of  the  patient  to 
the  greatest  possible  extent.  When  constipation  is  present,  coarser 
foods  and  foods  leaving  a  considerable  residue  are  indicated. 
Even  when  the  general  nutrition  is  normal  a  course  of  hyperali- 
mentation may  put  an  end  to  the  nervous  symptoms  (see  page 
569).  When,  however,  wTell-marked  secretory  disturbances  are 
present,  the  diet  should  be  adapted  to  the  condition  of  the  secretion. 
Atonic  states  of  the  stomach  must  be  likewise  considered  in  pre- 
scribing diet.  Patients  whose  symptoms  appear  synchronously 
with  the  entrance  of  food  into  the  stomach  should  receive  a  bland, 
non-irritating  diet  at  the  commencement  of  the  treatment,  to  be 
gradually  changed  to  one  of  a  more  solid  consistency.  When  an 
aversion  or  distaste  for  meat  exists,  other  protein  foods  must  be 
substituted.  Sometimes,  however,  a  purely  vegetarian  diet  is 
followed  by  good  results.  When  meat  is  eliminated  from  the  diet, 
there  is  a  corresponding  diminution  of  gastric  secretion.  To 
supply  the  needed  stimulus  to  secretion,  meat  extracts  may  be 
prescribed.  The  meat-free  lactovegetable  diet,  as  sometimes  pre- 
scribed in  gastric  diseases,  is  not  identical  with  that  of  the  strict 
vegetarian,  who  places  great  stress  on  the  consumption  of  raw 
fruits  and  vegetables.  A  vegetarian  diet  proper  would  be  too  coarse, 
too  voluminous,  and  too  poor  in  iron,  for  patients  with  gastric  dis- 
ease. For  the  nervous  dyspeptic  the  so-called  lactovegetable  diet  is 
worthy  of  consideration;  this  diet  includes  certain  animal  products, 
such  as  milk,  butter,  cheese,  and  eggs.     Coarse  indigestible  food 


422    NERVOUS  DYSPEPSIA-— NEURASTHENIA  GASTRIC  A 


should  be  avoided  by  patients  suffering  from  nervous  dyspepsia, 
and  the  diet  should  possess  as  high  a  nutritive  value  as  possible 
in  proportion  to  the  amount  ingested.  Such  foods  as  radishes, 
celery,  fresh  fruit,  nuts,  almonds,  dates,  horseradish  and  mush- 
rooms should  not  be  permitted  this  class  of  patients.  These  food 
articles  are,  however,  suitable  for  dyspeptic  patients  suffering  from 
constipation,  provided  the  state  of  their  nutrition  is  good  and  their 
symptoms  are  not  associated  with  the  ingestion  of  food. 

In  prescribing  a  lacto vegetable  diet  the  physician  should  take  into 
consideration  the  individual  requirements  of  the  patient.  While 
green  vegetables  may  be  used  in  large  quantities,  they  should  be 
prepared  and  served  in  a  finely  divided  state  or  in  the  form  of 
puree.  Dry  vegetables  and  leguminous  flours  rich  in  protein 
should  be  prescribed  in  liberal  quantities.  Flour  and  egg  dishes 
in  the  form  of  puddings,  jam,  and  fruit  juices  are  well  borne  by 
the  nervous  dyspeptic.  The  unfermented  juice  of  grapes,  possess- 
ing a  comparatively  high  nutritive  value,  is  a  suitable  beverage. 
Of  baked  foods,  wheat  bread,  zwieback,  rusks,  biscuits,  and  brown 
bread  may  be  prescribed  (see  page  655). 

Lacto  vegetable  Diet  List  (Wegele). 


Protein. 

Fat. 

Carbohydrate 

Morning 

250  Gm.  milk  cocoa  . 

9.0 

10.0 

72.50 

100  Gm.  roUs       .... 

9.0 

1.0 

58.00 

30  Gm.  butter    .      . 

0.5 

24.6 

0.15 

Forenoon 

250  Gm.  milk  pap  with  white 

of  egg 

12.0 

8.0 

11.00 

Noon 

250  Gm.  vegetables  with  rice 

5.0 

18.0 

20.00 

250  Gm.  pudding 

15.0 

25.0 

50.00 

150  Gm.  apple  sauce 

20.00 

Afternoon  250  Gm.  milk  cocoa  . 

3.0 

10.0 

72.50 

100  Gm.  rolls        .... 

9.0 

1.0 

58.00 

30  Gm.  butter    .... 

0.6 

24.6 

0.15 

Evening 

200  Gm.  gruel  with  yolk  of 

3.5 

7.5 

18.00 

200  Gm.  water  noodles  . 

5.0 

1.5 

40.00 

125  Gm.  plums    .... 

0.4 

. . 

8.30 

100  Gm.  roUs       .... 

9.0 

1.0 

58.00 

30  Gm.  butter    .... 

0.6 
81.6 

24.6 

0.15 

156.8 

486.75 

300.0 

1300.0 

2060.00 

Total  combustion  value,  3660  calories. 

The  protein  in  lactovegetable  diet  may  be  supplied  in  the  form 
of  eggs,  milk,  and  cheese;  the  fat  constituent  of  such  diet  is  derived 
from  butter,  oil,  milk,  and  cream.  Milk  should  be  fed  to  this 
class  of  patients  in  large  quantities,  pure,  or  as  buttermilk,  sour 
milk,  kefir,  or  yoghurt  (see  page  164).  Yoghurt  is  said  to  possess 
the  power  of  lessening  putrefactive  processes  in  the  intestinal  tract. 
In  prescribing  a  lactovegetable  diet  the  condition  of  the  gastric 
secretion  should  be  closely  studied.     In  order  to  assist  the  patient 


TREATMENT  423 

in  maintaining  a  fair  appetite,  monotony  in  articles  of  food  pre- 
scribed should  be  avoided.  Of  beverages,  tea  is  preferable  to  coffee. 
Alcoholic  drinks  should  be  avoided  entirely. 

Physical  Treatment. — Hydrothcrapeutic  measures  are  indicated 
for  the  genera]  nervous  condition  which  characterizes  patients 
suffering  from  nervous  dyspepsia.  These  measures  consist  of  cool 
rubbings,  half-baths,  cool  douches,  and  cold  baths.  The  Scotch 
douche,  alternate  cold  and  hot  applications,  may  be  used  locally 
over  the  region  of  the  stomach.  (See  Chapter  XII.)  Patients 
whose  state  of  nutrition  is  good  should  be  persuaded  to  persevere 
in  gymnastic  exercises;  those  in  a  run-down  condition  should  not 
undertake  exertion  of  any  kind  before  the  condition  of  their  nutri- 
tion has  improved.  Massage,  including  vibratory  treatment,  may 
be  instituted  for  the  purpose  of  stimulating  tissue  metamorphosis; 
it  may  include  the  whole  body  or  simply  the  stomach  or  abdomen. 
Electric  treatment,  galvanic  or  faradic,  of  the  stomach  and  intes- 
tine, may  be  applied  with  advantage.     (See  Chapter  X.) 

Whenever  gastroenteroptosis  is  a  complication  in  nervous  dys- 
pepsia, the  treatment  indicated  for  this  condition  and  described  in 
detail  in  Chapter  XXX  should  be  instituted. 

Sea-icater  Therapy. — Good  results  have  frequently  been  obtained 
from  the  subcutaneous  injection  of  isotonic  sea  water  in  the  treat-, 
ment  of  cases  of  nervous  dyspepsia  of  obscure  origin.  The  results, 
if  beneficial,  are  apparent  soon  after  beginning  the  treatment. 
It  has  been  clinically  demonstrated  that  sea-water  plasma  is  a 
powerful  tonic  to  the  nervous  system.  It  stimulates  metabolism 
to  such  a  degree  that  the  appetite  improves  and  there  is  an  increase 
in  the  body  weight.  The  water  relieves  pain,  allays  nervous  irri- 
tability, and  induces  restful  sleep;  there  is  a  general  improvement 
in  tone  throughout  the  entire  nervous  system,  and  the  bowels 
move  regular^. 

The  therapy  of  sea  water  depends  upon  Quinton's  law  of  marine 
constancy:  "Animal  life,  which  appears  as  a  cell  in  seas  of  well- 
determined  saline  concentration,  in  order  to  maintain  its  optimum 
cellular  activity  has  always  a  tendency  throughout  the  zoological 
scale  to  keep  the  cells  of  which  each  organism  consists  in  the  aquatic 
marine  conditions  of  their  origin." 

Geology  and  paleontology  agree  in  admitting  that  animal  life 
first  appeared  in  the  sea,  and  the  analysis  of  the  blood  serum  and 
ash  of  every  animal  in  the  entire  zoological  series  shows  that  the 
mineral  composition  of  the  medium  necessary  to  cellular  life  is 
the  same  as  that  of  the  original  seas.  It  is  from  these  facts  that 
Quinton  deduces  his  novel  conception  of  the  animal  organism  as 
an  actual  aquarium  in  which  the  cells  of  which  it  is  composed 
continue  to  live  under  the  aquatic  conditions  of  their  origin. 

Having  shown  that  the  primordial  seas  contained  only  0.8  per 
cent,  of  salts,  it  is  necessary,  in  order  to  produce  a  plasma  of  that 


424     NERVOUS  DYSPEPSIA— NEURASTHENIA  GASTRIC  A 


strength,  to  dilute  the  sea-water  of  the  present  day,  which  con- 
tains 3.3  per  cent.  For  the  purpose  of  diluting,  pure  spring  water 
containing  a  minimum  of  mineral  matter  and  free  from  bacteria 
is  used  in  the  proportion  of  five  parts  to  two  parts  of  sea  water. 
Great  care  must  be  observed  in  collecting  the  sea  water  in  order  to 
avoid  accidental  impurities.     It  should  be  obtained  not  less  than 

twenty  miles  from  any  port  or  any 
stream  flowing  from  a  port,  and  at  a 
depth  of  not  less  than  ten  meters. 
The  water  must  be  fresh,  three  weeks 
being  the  limit  of  time  which  should 
elapse  between  its  collection  and  its 
injection.  After  dilution  as  above 
it  should  be  filtered  through  a  por- 
celain filter  of  the  Pasteur  type. 
Every  precaution  for  the  sterilization 
of  vessels  should  be  observed,  but  the 
water,  aside  from  the  care  in  handling 
and  filtering  as  above,  is  not  to  be 
sterilized  further,  or  it  will  be  ren- 
dered therapeutically  useless.  After 
filtering  the  water  it  may  be  put  in 
flasks  or  ampoules  of  a  capacity  of 
30, 50, 100  Cc.  or  more,  as  the  conven- 
ience of  the  operator  may  require. 

The  injection  is  performed  with  a 
rubber  tube  1.5  meters  in  length  and 
ending  in  a  platinum-iridium  needle 
3  centimeters  long;  this  latter  should 
be  protected  by  a  glass  tube  (Fig. 
81,  T).  The  tube  and  needle  must 
be  boiled  before  connecting  with  the 
ampoule.  The  connection  is  made  as 
follows:  (1)  File  the  lower  end  of  the 
straight  tube,  A,  of  the  ampoule, 
break  its  point  and  join  it  to  B,  the 
free  end  of  the  rubber  tube.  (2) 
File  the  end  of  the  bent  tube  C, 
break  its  point,  and  hang  up  the  am- 
poule by  the  bend  in  the  tube  at  D, 
about  one  meter  above  the  patient. 
To  start  the  flow,  the  bulb  of  a  thermocautery  attached  to  the  end 
C  is  useful.  It  is  advisable  to  interrupt  the  tube  of  this  bulb  by 
a  glass  tube  packed  with  sterilized  absorbent  cotton  to  filter  the 
air.  (3)  The  ampoule  being  hung  up,  remove  the  glass  tube  ( T) 
and  allow  the  fluid  to  run  until  the  rubber  tube  is  quite  empty  of 
the  boiled  water  and  the  air  it  has  contained.    Make  sure  it  is  salt 


T 

Fig.  81. — Apparatus  for  the 
injection  of  sea  water. 


TREATMENT  42;") 

water  that  is  running  by  tasting  drops  on  the  back  of  the  hand 
periodically.    Then  stop  the  flow  with  the  clip  F. 

The  best  point  for  injection  is  behind  the  great  trochanter. 
After  the  skin  has  been  cleansed  with  alcohol  the  needle  should 
be  driven  its  whole  length  at  right  angles  to  the  skin  surface,  except 
in  very  thin  persons.  If  this  should  cause  pain,  withdraw  the  needle 
a  few  millimeters.  Subsequent  injections  should  be  made  in  the 
same  location,  twelve  hours  after  the  first  injection,  to  avoid  a  repe- 
tition of  the  pain  which  may  arise  from  stretching  of  the  tissues. 
After  injection  the  needle  wound  should  be  covered  for  a  minute 
or  two  with  a  pledget  of  cotton  soaked  in  alcohol;  it  will  have 
closed  up  by  that  time. 

The  quantity  of  sea  water  injected  is  of  great  importance.  It 
is  advisable  to  start  with  20  to  25  Cc.  (7  to  8  ounces).  There 
should  be  no  rise  of  temperature  or  other  symptom  of  reaction. 
If  symptoms  of  malaise  appear,  the  dose  must  be  decreased;  if  there 
is  no  reaction,  it  should  be  increased  to  50  Cc.  as  soon  as  possible, 
to  be  administered  every  other  day.  The  injections  may  be  given  at 
any  time  of  the  day.  The  treatment  need  not  cease  on  account  of 
menstruation.  When  it  is  well  tolerated  the  dyspeptic  symptoms 
diminish  progressively,  and  recovery  is  brought  about  after  a  course 
of  thirty  to  forty  injections. 

Drug  Treatment. — Drugs  occupy  an  important  place  in  the  treat- 
ment of  this  type  of  dyspepsia.  The  tonics,  stomachics,  sedatives 
and  hypnotics  are  all  valuable.  When  nervous  irritability  is 
marked,  the  bromids  may  be  prescribed.  Chloral  hydrate  in  small 
doses,  0.1  to  0.3  Gm.  (1|  to  5  grains),  may  be  prescribed,  to  be  taken 
three  or  four  times  a  day.  Insomnia  may  be  combated  by  veronal, 
trional,  or  chloral  hydrate,  the  last  in  the  dose  of  2  or  3  Gm.  (30 
to  45  grains)  per  rectum  in  a  mucilaginous  vehicle.  Deficient 
appetite  calls  for  bitters  and  stomachics. 

WTien  constipation  is  a  complication  it  should  be  treated  by 
other  means  than  purgatives.  A  diet  should  be  prescribed  which 
leaves  large  residues  in  the  intestine  (see  Chapter  VII) ;  abdominal 
massage,  faradization  of  the  rectum  and  abdomen,  and  enemata  in 
which  olive  oil  or  cottonseed  oil  has  been  incorporated,  will  usually 
serve  to  counteract  the  constipation  (see  page  223). 

Glycerophosphates  and  lecithin  have  been  used  with  marked 
success  in  the  treatment  of  nervous  dyspepsia.  In  addition  to  the 
present  official  elixir  containing  the  glycerophosphates  of  sodium 
and  calcium,  a  compound  elixir  containing  the  glycerophosphates 
of  calcium,  sodium,  iron,  manganese,  quinin  and  strychnin  is 
largely  used.  The  glycerophosphates  and  lecithin  in  various  com- 
binations are  placed  before  the  profession  in  ampoule  form,  and 
may  be  administered  hypodermically,  together  with  the  iron  and 
arsenic  preparations  described  on  page  581.  Cacodylate  of  sodium 
hypodermically,  0.5  Gm.  (7|  grains),  has  proved  of  great  value  in 


426     NERVOUS  DYSPEPSIA— NEURASTHENIA  GASTRICA 

my  work.  I  give  this  preparation  once  a  day  for  four  weeks.  It 
is  a  great  stimulant  to  metabolism,  and  so  affects  nutrition  as  to 
bring  about  marked  improvement  in  the  general  nervous  condition. 

Menthol  has  proved  valuable  in  the  treatment  of  nervous  dys- 
pepsia. The  pain,  vomiting,  anorexia  or  flatulence  often  subsides 
at  once,  and  permanent  relief  results.  It  should  be  prescribed  in 
the  dose  of  0.3  Gm.  (5  grains),  three  times  a  day.  It  can  be 
advantageously  combined  with  the  alkalis. 

The  author  has  found  the  following  prescriptions  of  value : 

In  cases  of  hypersecretion: 

Gm.  or  Cc. 
1$ — Extracti  belladonnse  foliorum    .  015  gr.  viiss 

Magmas  magnesiae     .      .      q.  s.  ad     120 10  %\v 

Misce. 
Sig. — Teaspoonful  three  times  daily,  a  quarter  of  an  hour  before  meals. 

In  cases  of  fermentation  add  resorcinol : 

Gm.  or  Cc. 

R, — Resorcinolis 6|0  5iss 

Extracti  belladonnse  f oliorum    .  0  [  5  gr.  viiss 

Magmae  magnesias  .      .      q.  s.  ad       120  [0  §iv 

Misce. 

Sig. — Teaspoonful  three  times  a  day,  a  quarter  of  an  hour  before  meals. 

In  cases  of  excessive  acidity: 

Gm.  or  Cc. 
R — Sodii  bicarbonatis      ......       60 1 0  5  ij 

Sig. — Teaspoonful  in  a  half-glass  of  water,  one  hour  after  meals. 

In  cases  of  constipation  with  excessive  acidity: 

Gm.  or  Cc. 

1$ — Magnesii  oxidi 2010  3v 

Sodn  bicarbonatis     .....       60 10  §ij 

Misce. 
Sig. — Teaspoonful  in  a  half-glass  of  water,  one  hour  after  meals. 

In  cases  of  diarrhea  with  excessive  acidity: 

Gm.  or  Cc. 
R — Bismuthi  subcarbonatis, 

Cretse  prasparatae, 

Pulveris  ossis aa      30 JO  5j 

Misce. 

Sig. — -Teaspoonful  in  water  one  hour  after  meals. 

In  cases  of  subacidity  the  following  bitter  tonics : 

Gm.  or  Cc. 
R — Tincturae  nucis  vomicae  .      ...         810  5jj 

Tincturae  cinchonae  comp.     q.  s.  ad       90  [0  §iij 

Misce. 
Sig. — Teaspoonful  three  times  a  day,  before  meals. 

Gm.  or  Cc. 
R — Tincturae  gentians  compositae  .      .       60 10  §ij 

Misce. 
Sig. — Teaspoonful  in  water  three  times  a  day,  before  meals. 


TREATMENT  427 

In  cases  of  deficient  hydrochloric  acid: 

Gm.  or  Cc. 
I$— Acidi  hydrochlorici  diluti     ...      120 10  5iv 

Misce. 
Sig. — Fill  double  capsule  and  take  four  such  with  water,  at  intervals  of  ten 
minutes,  after  each  meal.     (Seepage  261.) 

Gm.  or  Cc. 

1^— Glyceriti  pepsini,  N.  F.        ...     240 1 0  3  viij 

Misce. 

Sig. — Tablespoonful  in  water  during  meals. 

In  cases  of  impaired  motility: 

Gm.  or  Cc. 
1$ — Strychninse  sulphatis      ....     0 1 003  gr.  ^ 

Misce  et  ft.  pil.  vel  tab.  no.  i. 
Sig.— One,  three  times  a  day,  before  meals. 

Surgical  Treatment. — Many  cases  of  nervous  dyspepsia  may 
require  surgical  intervention,  and  our  attention  must  always  be 
given  to  the  possible  presence  of  gallstones  or  chronic  appendicitis. 
Surgeons  have  repeatedly  called  attention  to  the  frequency  with 
which  chronic  appendicitis  and  gallstones  are  associated  with  gastric 
symptoms.  It  is  now  established  that  appendicular  disease  does 
produce  definite  gastric  symptoms,  a  condition  for  which  Paterson 
suggests  the  term  "appendicular  gastralgia."     (See  page  691.) 

Clinical  experience  presents  strong  evidence  that  there  are  gastric 
disturbances  which  are  relieved  or  even  completely  dissipated 
by  removal  of  the  appendix.  Examination  of  the  appendices 
removed  in  association  with  gastralgia,  pylorospasm,  gastric  and 
duodenal  ulcers,  cholecystitis,  and  cholelithiasis,  shows  that  there  is 
a  high  percentage  of  appendices  with  partially  or  completely  obliter- 
ated lumen  in  all  of  these  conditions.  MacCarty  and  McGrath 
found  that  of  365  patients  on  whom  cholecystectomy  was  performed, 
13  per  cent,  gave  definite  histories  of  pain  and  soreness  in  the  region 
of  the  appendix.  In  59  of  these  patients  with  cholecystitis  the 
appendices  were  removed  and  69  per  cent,  of  them  showed  un- 
doubted gross  or  microscopic  evidence  of  inflammation,  varying 
from  a  chronic  catarrhal  condition  to  complete  obliteration  and 
peri-appendicitis. 

From  a  careful  study  of  271  cases  of  achlorhydria  gastrica  hemor- 
rhagica, with  a  complex  of  gastric  symptoms,  Pilcher  found  that 
in  156  cases  the  onset  seemed  to  bear  an  immediate  and  direct 
relation  to  various  diseases.  In  100  of  these  patients  operated  on, 
the  trouble  in  36  was  found  to  be  due  to  appendicitis,  in  32  to  gall- 
bladder trouble,  in  16  to  gall-bladder  and  pancreatic  disease  com- 
bined, in  12  to  appendicitis  and  gall-bladder  involvement  combined, 
and  in  16  the  stomach  alone  was  found  diseased.  In  24  there  was 
pylorospasm — in  18  with  appendicitis  and  in  6  with  gall-bladder 


428     NERVOUS  DYSPEPSIA— NEURASTHENIA  GASTRICA* 

involvement.  The  achlorhydria  is  attributed  to  reflex  inhibition 
of  gastric  secretion  by  disease  elsewhere  than  in  the  stomach. 
From  this  it  would  seem  that  hypersecretion  and  hyposecretion  of 
hydrochloric  acid  may  be  due  to  the  same  remote  causes  in  different 
patients  (see  page  464) . 

UMBILICAL  DYSPEPSIA.1 

A  defect  in  the  abdominal  parietes  preventing  closure  of  the 
umbilical  canal  results  in  what  is  known  as  a  congenital  opening. 
Only  when  there  is  protrusion  do  we  regard  it  as  a  hernia.  It  is 
a  somewhat  common  occurrence  to  find  the  opening  at  the  navel 
unobliterated.  The  defect  is  at  the  opening  for  the  omphalomesen- 
teric duct  and  the  urachus.  In  the  majority  of  instances  no  injury 
results  from  this  non-closure.  This  umbilical  opening  may  at  first 
be  very  small — so  small  as  to  escape  the  notice  df  the  examining 
physician— and  later  assume  large  dimensions.  It  is  always  con- 
genital in  origin. 

All  these  patients  have  symptoms  of  nervous  dyspepsia  due  to 
increased  irritability  of  the  autonomic  nervous  system.  They 
are  often  free  from  distressing  symptoms  for  days,  and  then,  from 
some  trivial  cause,  the  symptoms  recur.  The  appetite  is  apt  to 
be  capricious;  coarse  food  may  be  taken  without  aggravation  of 
symptoms,  and  then  again  a  diet  which  ordinarily  might  be  taken 
with  impunity  by  a  person  suffering  from  organic  disease  of  the 
gastro-intestinal  tract  is  rejected  as  not  agreeing  with  the  patient. 

The  patient  complains  of  fulness  of  the  head,  headache,  inability 
to  work,  vertigo,  lassitude,  and  depression.  He  may  experience 
uneasy  sensations  one  or  two  hours  after  meals,  or  have  a  feeling 
of  heaviness  immediately  after  eating.  The  degree  of  discomfort 
does  not  depend  upon  the  quality  or  quantity  of  food  taken.  The 
patient  is  usually  constipated.  The  nutrition  is  good.  When  the 
subjective  symptoms  become  severe,  loss  of  weight  results  from 
refusal  of  the  patient  to  partake  of  adequate  nourishment.  Deep 
palpation  with  the  ball  of  the  finger  over  the  umbilicus  elicits  severe 
pain.  This  may  radiate  in  different  directions,  or  be  referred  to 
some  distant  part  of  the  abdomen.  As  soon  as  the  pressure  is 
released,  the  pain  ceases.  The  stomach  may  function  in  a  per- 
fectly normal  manner.  In  some  cases,  however,  hyperacidity  is 
present.  The  diagnosis  is  made  by  the  pressure  pain  over  the 
umbilicus,  together  with  the  discovery  of  the  failure  of  parietal 
union. 

The  treatment  consists  in  drawing  together  both  sides  of  the 
recti  muscles  at  the  level  of  the  umbilicus  and  securing  them  in 
this  position  by  adhesive  plaster.    This  induces  a  firmness  in  the 

1  Charles  D.  Aaron,  Umbilical  Dyspepsia,  Transactions  of  the  American  Gastro- 
enterological Association,   1916. 


UMBILICAL  DYSPEPSIA  429 

parts  so  thai  an  increase  in  the  intra-abdominal  pressure  will  not 
irritate  the  opening  at  the  umbilicus  when  the  underlying  organs 
are  forced  against  it.     The  plaster  may  he  allowed  to  remain  two 

or  three  weeks  without  discomfort.  After  the  adhesive  plaster  has 
been  applied  two  or  three  times,  complete  relief  of  the  digestive 
troubles  ensues.  ( Closure  of  the  unobliterated  opening  by  surgical 
intervention  is  the  ideal  treatment. 


CHAPTER  XX. 

SECRETORY  NEUROSES. 

Hyperchlorhydria — Hyperacidity — Superacidity. 

HYPERCHLORHYDRIA. 

The  term  "hyperchlorhydria"  is  applied  to  that  condition  of 
the  gastric  secretions  in  which  the  quantity  of  gastric  juice  is 
normal  but  the  percentage  of  free  hydrochloric  acid  higher  than 
normal.  The  hyperacid  gastric  juice  is  secreted  during  digestion 
only,  from  the  stimulus  of  food  in  the  stomach.  Some  writers 
maintain  that  hyperacidity  is  not  a  clinical  entity,  but  merely  one 
aspect  of  hypersecretion.  This  view  is  in  opposition  to  a  con- 
vincing array  of  clinical  facts  and  observations;  we  are  justified 
in  looking  upon  hyperacidity  as  a  condition  entirely  independent 
of  hypersecretion. 

Hyperacidity  is  primarily  a  disturbance  of  the  gastric  function 
in  which  the  mucous  membrane  of  the  stomach,  under  the  stimulus 
of  food,  secretes  gastric  juice  containing  an  excessive  amount  of 
free  hydrochloric  acid.  It  may  be  of  purely '  nervous  origin,  a 
secretory  neurosis  dependent  upon  the  abnormal  stimulation  or 
inhibition  of  certain  nerve  trunks  leading  to  the  stomach.  Or  it 
may  be  due  to  an  organic  disease  of  the  gastro-intestinal  tract  or 
some  remote  organ  which  reflexly  sends  impulses  which  disturb 
the  vegetative  nervous  system  (see  page  387).  It  is  not  always 
possible  to  draw  a  distinct  line  between  the  two  varieties,  neurotic 
and  organic;  so  they  may  be  considered  together.  These  forms  of 
hyperacidity  are  designated  genuine,  in  contradistinction  to  those 
which  occur  secondarily  as  sequelae  of  other  pathologic  processes. 
Hyperacidity  in  chronic  gastritis  (gastritis  acida)  or  gastric  ulcer 
may  be  either  secondary  or  primary — the  result  or  the  cause. 
The  clinical  symptoms  characteristic  of  hyperacidity  are  sometimes 
misleading;  the  symptoms  may  be  present  when  the  gastric  juice 
is  of  normal  acidity,  as  shown  by  examination  after  a  test  meal, 
or  they  may  be  absent  when  the  test  shows  a  marked  hyperacidity. 
The  presence  or  absence  of  subjective  symptoms  is  doubtless  due 
to  differences  in  the  sensibility  of  the  gastric  mucous  membrane. 

Etiology. — Hyperchlorhydria  is  of  very  frequent  occurrence.  In 
almost  50  per  cent,  of  all  patients  suffering  from  digestive  disorders, 
acidity  of  the  gastric  juice  is  somewhat  increased.  It  is  a  dis- 
ease of  both  sexes.     While  it  is  met  with  chiefly  in  adults,  neither 


HYPERCHLORHYDRIA  431 

the  young  nor  the  old  are  exempt.  Persons  of  a  nervous  tem- 
perament, those  suffering  from  neurasthenia,  hypochondria,  or 
melancholia,  are  apt  to  be  its  victims.  Hyperchlorhydria  has 
followed  grief,  worry,  and  mental  overwork.  In  the  majority  of 
cases  the  cause  is  psychic.  Bad  habits  of  eating,  the  quick-lunch 
counter,  insufficient  mastication  of  food,  beverages  either  too  hot 
or  too  cold,  alcohol,  tobacco,  highly  spiced  dishes,  all  predispose 
to  hyperchlorhydria.  It  frequently  accompanies  gastric  and 
duodenal  ulcer  and  constipation.  In  incipient  phthisis,  cardiac 
diseases,  appendicitis,  uterine  diseases,  chlorosis,  cholelithiasis,  and 
in  many  other  conditions,  hyperchlorhydria  has  been  noted,  but 
the  bearing  of  these  diseases  upon  the  excessive  acidity  is  by  no 
means  clear. 

Pathology. — No  characteristic  pathologic  changes  have  been  found 
in  the  few  cases  in  which  autopsy  has  been  made. 

Symptoms. — Hyperchlorhydria  develops  gradually.  At  first  the 
patient  experiences  an  uneasy  sensation  one  or  two  hours  after 
dinner.  Later  this  feeling  becomes  aggravated  into  one  of  distress 
occurring  from  one  to  three  hours  after  each  meal.  The  subjective 
discomforts  of  the  patient  begin  at  the  height  of  digestion,  during 
which  time  the  acid  secretion,  and  especially  the  free  hydrochloric 
acid,  greatly  exceeds  the  normal.  The  degree  of  discomfort  at  this 
time  does  not  depend  upon  the  quantity  of  acid  so  much  as  upon 
the  sensitiveness  of  the  gastric  mucosa.  Low  degrees  of  hyper- 
acidity sometimes  provoke  painful  symptoms.  The  pain  may  last 
for  an  hour  or  two,  or  longer,  and  then  disappear.  Patients  are 
frequently  able  to  predict  the  exact  time  the  pain  or  distress  is 
likely  to  occur.  The  pains  vary  not  only  in  duration  but  in  severity, 
from  mild  distress  to  violent  cramping  seizures  (pylorospasm)  caused 
by  obstruction  to  the  outflow  of  the  acid  contents,  together  with 
violent  peristaltic  movements  of  the  stomach.  Patients  are, 
as  a  rule,  able  to  ease  their  pains  by  partaking  of  some  article  of 
food.  During  the  painful  attacks  the  region  of  the  stomach  is 
distended  and  sensitive  to  pressure.  Besides  the  gastric  pain, 
there  are  very  often  severe  headache  and  vertigo.  Constipation  is 
common.  The  victims  of  hyperchlorhydria  do  not  usually  produce 
the  impression  on  the  observer  of  being  very  sick.  They  appear 
to  be  well  nourished,  except  in  cases  where  faulty  and  insufficient 
diet  has  been  maintained  for  a  long  time. 

Diagnosis. — The  diagnosis  is  confirmed  only  by  examination  of 
the  stomach  contents.  What  remnants  of  food  are  found  appear 
finely  divided  and  well  digested.  The  tests  for  free  hydrochloric 
acid  are  positive.  Clinicians  calculate  the  normal  total  acidity 
after  a  test  breakfast  to  be  40  to  60;  in  hyperacidity  the  total 
acidity  is  75  to  80.  A  total  acidity  of  160  has  been  recorded.  It 
is  important  to  ascertain  the  quantity  of  free  hydrochloric  acid  in 
every  case.     A  disk  of  coagulated  egg  protein  placed  in  the  filtrate 


432  SECRETORY  NEUROSES 

of  the  gastric  contents  will  become  digested  in  a  short  time.  Gastric 
contents  obtained  three  or  four  hours  after  the  test  meal  show  that 
meat  has  been  entirely  digested,  while  starches  are  but  slightly 
changed.  The  filtrate  of  gastric  contents  after  either  a  test  dinner 
or  a  test  breakfast  shows  the  presence  of  starch  or  large  quantities 
of  erythrodextrin.  The  addition  of  a  few  drops  of  Lugol's  solution 
to  the  filtrate  will  produce  either  a  blue  color  or  an  intense  dark 
red.  The  presence  of  the  unaltered  or  slightly  altered  starches 
is  due  to  the  fact  that  hydrochloric  acid  begins  to  be  secreted 
directly  after  the  ingestion  of  food,  and  amylolysis  is  thus  inter- 
rupted. The  test  breakfast  and  the  test-diet  stool  are  characteristic 
(see  pages  94  and  131). 

Prognosis. — Hyperchlorhydria  or  hyperacidity  may  yield  to 
appropriate  treatment.  The  prognosis  is,  as  a  rule,  good,  except 
in  some  very  protracted  and  severe  cases.  Should  there  be  pyloro- 
spasm,  atony  and  dilatation  of  the  stomach  are  apt  to  supervene. 
Treatment.— The  treatment  in  most  cases  is  medical,  though  sur- 
gery is  sometimes  necessary.  Should  protracted  medical  treatment 
fail  to  heal  a  gastric  or  duodenal  ulcer,  surgery  is  imperative.  When 
there  is  chronic  appendicitis,  obstructive  gallstone  formation,  intes- 
tinal adhesions,  lacerated  cervix,  etc.,  prompt  surgical  intervention 
is  called  for;  but  even  after  operation,  medical  treatment  of  the 
hyperchlorhydria  should  be  continued. 

Hygienic  Treatment- — In  view  of  the  fact  that  hyperchlorhydria 
is  often  caused  by  grief,  worry,  or  mental  overwork,  it  would 
appear  that  the  first  thing  to  do  is  to  regulate  the  daily  life  and 
habits  of  the  patient.  Business  men,  lawyers,  physicians,  clergy- 
men, those  whose  labor  entails  great  responsibility,  should  be  sent 
away  from  their  work  to  an  entirely  different  environment  where 
they  may  find  at  least  temporary  relief  from  the  strain.  Women  in 
social  circles  must  be  persuaded  to  lead  a  quieter  life.  Patients 
among  the  wealthy  leisure  class  who  have  too  much  time  to  think 
over  their  bodily  functions  must  be  given  some  occupation  which 
will  engage  the  mind.  Persons  with  a  predisposition  to  hyper- 
chlorhydria should,  as  a  prophylactic  measure,  avoid  errors  in 
diet,  mental  overexertion,  and  anger. 

Dietetic  Treatment— The  dietetic  treatment  is  of  the  greatest 
importance  in  cases  of  uncomplicated  hyperchlorhydria.  In  the 
first  place,  extremes  of  temperature  should  be  avoided  in  both 
food  and  drink.  Food  should  be  eaten  slowly  and  thoroughly 
masticated,  not  only  to  facilitate  salivary  digestion,  but  to  avoid 
irritating  the  stomach  mechanically.  All  substances  that  are 
likely  to  irritate  the  gastric  mucosa  must  be  eliminated  from  the 
dietary.  All  kinds  of  acids,  including  the  organic,  such  as  citric, 
tartaric,  and  acetic,  must  be  forbidden;  also  spices  of  all  kinds — 
pepper,  mustard,  horseradish,  etc.  The  salt-free  diet  should  be 
instituted  in  every  case  of  persistent  hyperchlorhydria,  to  eliminate 


H  Y PERCH LORII YDRIA  133 

the  chlorin.  Whisky  and  wines  are  in  the  prohibited  list .  To  season 
the  food  the  following  chlorin-free  inorganic  salt  mixture  can  be  used 
as  a  substitute  for  common  salt: 

Gm. 

Dicalcium  phosphate 5  8 

Monomagnesium  phosphate 3  4 

Dipotassium  phosphate 7  7 

Potassium  citrate 17 

Sodium  citrate 7  4 

Calcium  lactate 4  0 

Mix  and  pulverize. 

Jacobson  recommends  fresh  meat,  potatoes,  oatmeal,  carrots  and 
cauliflower  cut  fine,  to  be  boiled  for  hours  with  several  changes 
of  water;  stewed  apples,  prunes  and  apricots;  very  weak  tea  and 
coffee;  butter  freed  from  salt  by  washing  small  particles  thoroughly 
in  running  water;  one  egg  and  about  50  Cc.  of  milk  or  cream  per  day, 
but  no  more.  Distilled  water  is  used  for  drinking.  A  sample  diet 
for  one  day  might  be  as  follows: 

Breakfast. — Oatmeal  gruel  with  sugar  and  a  little  cream;  apple 
sauce;  very  weak  coffee  with  sugar  and  cream. 

Dinner. — Fresh  meat,  boiled  and  hashed;  potatoes  boiled  and 
mashed;  carrots  likewise;  special  salt-free  butter;  orange  juice 
diluted  and  sweetened. 

Supper. — One  egg,  raw,  boiled  or  poached;  boiled  rice;  puree  of 
prunes;  very  weak  tea  with  sugar  and  cream. 

The  food  should  be  rich  in  protein  and  as  poor  as  possible  in 
starchy  substances.  The  total  acidity  of  the  gastric  secretions  is 
much  greater  with  a  protein  than  with  a  carbohydrate  diet,  but 
the  amount  of  free  hydrochloric  acid  is  much  less.  Owing  to  the 
large  percentage  of  extractives  in  meat  which  excite  the  flow. of 
gastric  juice,  it  seems  advisable  to  substitute  some  other  form  of 
protein,  as  eggs,  milk,  cheese,  or  vegetable  protein.  However, 
when  meat  is  prescribed,  it  should  be  well  cooked  to  remove  the 
extractives.  Raw  meat  should  be  avoided,  owing  to  its  excessively 
stimulating  effect  on  gastric  secretion.  Oatmeal,  aleuronat  meal, 
bread  and  cocoa,  all  of  which  are  rich  in  protein,  are  useful  food 
substances  in  the  treatment  of  hyperchlorhydria. 

Carbohydrates  should  not  be  eliminated  entirely  from  the  diet, 
but  should  be  restricted.  They  may  be  taken  in  finely  divided 
form;  that  is,  vegetables  such  as  spinach  and  cauliflower  must 
be  taken  as  puree.  Salads  and  fresh  fruits  are  to  be  avoided. 
When  free  hydrochloric  acid  appears  early,  interrupting  the  diges- 
tion of  carbohydrates,  amylolysis  may  be  assisted  by  the  use  of 
dextrinated  carbohydrates  (zwieback,  toast).  Sugar  has  been 
found  valuable  in  the  dietary  of  hyperacidity,  inasmuch  as  con- 
centrated saccharated  solutions  diminish  not  only  the  total  acidity, 
but  likewise  the  free  hydrochloric  acid,  to  a  marked  degree.  Sugar 
may  be  given  in  a  variety  of  forms,  such  as  sweet  dishes,  jellies, 
jam,  and  honey. 
28 


434  SECRETORY  NEUROSES 

Fats  fulfil  the  same  role  as  sugar.  It  has  been  demonstrated 
that  fat  not  only  hinders  gastric  secretion,  but  diminishes  the 
quantity  of  free  hydrochloric  acid.  Fats  can  be  given  after  it 
has  been  ascertained  that  they  do  not  disturb  the  motility  of  the 
stomach  or  interfere  with  the  assimilation  of  other  foods.  Bacon 
provides  fat  in  an  agreeable  form.  Milk,  cream  and  butter  are 
indicated. 

Oils  of  various  kinds  have  been  employed  with  good  results  in 
the  treatment  of  h}"perchlorhydria.  Olive  oil,  given  in  connection 
with  the  usual  test  breakfast,  decreases  the  gastric  acidity  at  the 
end  of  the  hour  and  retards  the  evacuation  of  the  stomach.  The 
action  of  oil  on  the  gastric  functions  is  only  a  temporary  one. 
It  has  no  effect  on  subsequent  meals  unaccompanied  by  oil.  The 
therapeutic  value  of  oil  is  apparent.  In  suitable  cases  it  is  prefer- 
able to  antacids  because  of  its  caloric  value.  In  hyperchlorhydria 
it  should  precede  the  meal. 

Wiley  says  that  cottonseed  oil  may  be  safely  substituted  for 
olive  oil.  When  used  with  salt  on  bread  it  makes  a  very  acceptable 
substitute  for  cream  and  butter,  and  is  free  from  the  germs  of  the 
diseases  we  contract  from  the  animal  world.  Xot  only  is  cottonseed 
oil  more  easily  digested  than  corn  oil,  peanut  butter,  or  even  olive 
oil;  it  does  not  ferment  in  the  stomach. 

Large  quantities  of  fat  are  particularly  indicated  in  cases  of 
hyperacidity  accompanied  by  constipation.  On  the  other  hand, 
a  purely  la cto vegetable  (see  page  422)  or  meat-poor  regimen  is 
recommended  in  pronounced  nervous  forms  of  hyperacidity;  the 
vegetables  should  be  thoroughly  cooked  and  finely  divided. 

Regarding  the  frequency  of  meals,  it  is  advisable  to  eat  five  or 
six  times  a  day,  three  heavy  and  two  or  three  light  meals. 

Outline  of  Diet  est  Hyperchlorhyeria  (Ees-hohx). 

Calories. 

7.30  a.m.      Two  eggs,  50  Gm 160 

White  bread,  50  Gm 128 

Butter,  20  Gm.      .      .    ' 163 

Milk,  250  Cc 169 

10.30  a.m.      Matzoon  or  milk,  200  Cc 135 

Crackers  or  bread,  30  Gm 77 

Butter,  10  Gm 81 

1.00  p.m.       Broiled  meat,  100  Gm. 210 

Mashed  potatoes,  50  Gm.            .    " 63 

Bread,  30  Gm 77 

Butter,  10  Gm 81 

Weak  tea  or  Vichy  water,  200  Cc 

3.30  p.m.       Same  as  at  10.30  a.m 293 

6.30  p.m.      Soup  (with  barlev  or  vermicelli),  200  Gm.        ...  100 

Bread  and  butter  (bread,  30  Gm.;  butter,  10  Gm.)     .  158 

Meat  broiled  or  cooked,  100  Gm 210 

Potatoes,  baked,  50  Gm 60 

Green  vegetables  (spinach,  green  peas),  50  Gm.    .      .  80 

Coffee  (half  milk),  100  Cc 34 

10.00  p.m.       Oysters  and  crackers,  or  cold  meat  sandwich  .      .      .  260 

2539 


HYPERCHLORHYDRIA  435 

Beverages  taken  at  meals  are  harmless,  inasmuch  as  they  dilute 
the  gastric  juice.  Alkaline  mineral  waters,  Vichy,  and  California 
Seltzer  waters  containing  no  carbon  dioxid,  may  be  prescribed  in 
large  quantities.  Beer  and  coffee  should  be  avoided.  Cocoa  and 
weak  tea  well  diluted  with  milk  are  permissible.  Pure  milk,  how- 
ever, is  the  ideal  beverage  in  these  cases. 

Medicinal  Treatment. — Astringents. — The  astringents  are  among 
the  most  valuable  drugs  we  have  in  the  treatment  of  hyperchlor- 
hydria.  Their  action  is  confined  to  the  gastric  mucosa.  They 
diminish  the  intensity  of  local  inflammation.  Astringents  are 
therefore  indicated  in  the  treatment  of  chronic  gastritis  when  the 
inflammatory  process  is  superficial.  Owing  to  their  inhibitory  effect 
upon  secretion  they  are  contra-indicated  when  the  acid  secretion  is 
normal,  subnormal,  or  absent. 

Among  the  most  valuable  astringents  are  the  salts  of  bismuth 
and  silver.  The  physical  effect  of  bismuth  subnitrate  is  the  forma- 
tion of  a  protective  layer  over  the  gastric  mucosa,  which  is  particu- 
larly desirable  where  abrasions  exist.  Bismuth  inhibits  gastric 
secretion;  the  subnitrate  materially  diminishes  the  quantity  of  free 
hydrochloric  acid. 

The  inhibitory  effect  of  bismuth  subnitrate  is  due  to  the  nitric 
acid  formed  by  the  action  of  hydrochloric  acid  upon  it.  Bismuth 
subnitrate  is  indicated  in  the  treatment  of  hyperacidity  and  hyper- 
secretion (see  page  265). 

Recent  experiments  show  that  the  silver  compounds  (silver 
nitrate,  protargol,  albargin)  diminish  the  quantity  of  gastric  juice 
in  inflammatory  conditions  of  the  gastric  mucous  membrane,  but 
slightly  increase  the  amount  of  hydrochloric  acid.  In  the  absence 
of  inflammation,  however,  the  silver  salts  were  found  to  increase 
gastric  secretion.  Nitrate  of  silver,  accordingly,  would  be  indi- 
cated in  cases  of  gastritis  with  either  normal  or  subnormal  acidity, 
rather  than  in  hyperacidity  or  hypersecretion.  I  have  obtained 
good  results,  however,  from  the  use  of  silver  nitrate  in  hyperacid 
conditions,  whether  accompanied  by  catarrh  or  not,  and  also  in 
hypersecretion.  Lavage  with  1:1000  nitrate  of  silver  will  promptly 
relieve  the  severe  pains  and  often  abate  the  annoying  s3~mptoms. 
Nitrate  of  silver  should  be  given  in  solution  (1:750  to  1:1000),  one 
tablespoonful  of  the  solution  in  a  half-glass  of  distilled  water  before 
meals  (see  page  267). 

Atropin.- — The  effect  of  astringents  is  directly  upon  the  gastric 
glands.  Atropin  acts  through  the  autonomic  nervous  system, 
inhibiting  gastric  secretion,  and  diminishing  the  quantity  of  hydro- 
chloric acid  in  the  gastric  juice  without  interfering  with  the  secre- 
tion of  pepsin.  Atropin,  furthermore,  acts  as  an  antispasmodic 
and  analgesic;  it  diminishes  the  sensibility  of  the  sensory  nerves. 
Atropin  sulphate  in  doses  of  \  to  1  milligram  (tto~  t0  ~io  grain), 
given  in  the  form  of  tablets,  is  a  useful  agent  for  promptly  relieving 


436  SECRETORY  NEUROSES 

the  painful  attacks  of  pylorospasm.  When  atropin  is  to  be  adminis- 
tered over  a  long  period  of  time  it  is  best  given  as  extract  of  bella- 
donna, 0.02  to  0.03  Gm.  (|  to  \  grain)  three  times  a  day,  before 
meals;  or  it  may  be  advantageously  given  with  astringents  and 
alkalis.  Atropin  is  a  poison,  and  when  it  is  necessary  to  secure 
its  therapeutic  effect  for  a  considerable  length  of  time  some  rela- 
tively harmless  substitute  should  be  considered.  Among  the  less 
poisonous  substitutes  we  have  eumydrin,  which  is  supposed  to  be 
fifty  times  less  toxic  than  atropin  (see  page  271).     In  doses  of 

1  to  3  milligrams  (g^  to  -^  grain)  eumydrin  can  be  given  for  some 
little  time  without  producing  any  severe  general  disturbances.  It 
is  very  satisfactory  in  gastric  neuroses  with  hyperchlorhydria  and' 
increasing  gastric  pains. 

Gm.  or  Cc. 

fy — Eumydrin 0[04  gr.  § 

Sacchari 6|0  5iss 

Misce  et  ft.  pulv.  no.  xx. 

Sig. — One,  three  times  a  day,  before  meals. 

Alkaloids. — Of  the  alkaloids,  codein  is  the  only  one  besides 
atropin  that  does  not  occasion  untoward  after-effects.  Morphin, 
after  temporarily  inhibiting  secretion,  is  apt  to  cause  a  very  copious 
flow  of  hyperacid  gastric  juice.  Dionin  and  pilocarpin  immedi- 
ately increase  the  secretion.  Codein  may  be  given  in  doses  of 
0.01  to  0.03  Gm.  (|  to  \  grain)  with  extract  of  belladonna  or  with 
alkalis  and  astringents  (see  page  271). 

Hydrogen  Peroxid. — It  has  recently  been  shown  that  hydrogen 
peroxid,  taken  internally,  reduces  the  total  acidity  and  especially 
the  proportion  of  hydrochloric  acid.  A  teaspoonful  of  hydrogen 
peroxid  may  be  taken  in  a  glass  of  water  after  meals  (see  page 
272). 

Magnesium  peroxid  has  been  found  useful  for  diminishing  hyper- 
aciditv.  The  dose  is  1  Gm.  (15  grains)  three  times  a  dav  (see  page 
273)." 

Analgesics. — The  following  analgesic  agents  have  been  found 
efficacious:  Cannabis  indica  extract,  0.01  to  0.05  Gm.  (\  to  1 
grain)  three  times  daily;  chloral  hydrate;  and  chloroform  water 
(1  :  200).  Cocain  is  efficacious  in  painful  vomiting.  Menthol 
and  validol  act  like  cocain.  The  bromids  are  occasionally  very 
useful  in  the  nervous  form  of  hyperacidity;  bromid  of  strontium, 

2  to  4  Gm.  (30  to  60  grains)  daily,  is  often  valuable. 

Acids. — Hyperacidity  can  frequently  be  relieved  by  giving  large 
doses  of  hydrochloric  acid,  which  exerts  an  inhibitory  influence  upon 
the  motor  reflexes  of  the  stomach.  Hypermotility  may  induce 
hyperacidity,  and  medicinal  hydrochloric  acid  arrests  the  rapid 
emptying  of  the  stomach  into  the  duodenum.  The  acid  should 
be  administered  before  meals.  These  patients  tolerate  the  usual 
doses  of  hydrochloric  acid  very  well,  in  contradistinction  to  those 
suffering  from  gastric  ulcer;  this  fact  is  of  value  in  differential 
diagnosis. 


HYPERCHLORHYDRIA  437 

Alkalis.-  Alkalis  an-  the  remedies  thai  arc  employed  mosl 
frequently  in  the  treatment   of  hyperchlorhydria.     Experimental 

research  concerning  the  effect  of  alkalis  in  the  stomach  has  estab- 
lished the  fact  that,  reaching  the  stomach  in  sufficient  quantity, 
they  are  capable  of  neutralizing  the  hydrochloric  acid  secreted. 
Magnesium  oxid  and  sodium  bicarbonate  serve  this  purpose. 
Sodium  bicarbonate  not  only  neutralizes  the  acid,  but  diminishes 
the  secretion;  but  magnesium  oxid  is  capable  of  neutralizing  a 
greater  amount  of  acid — in  the  same  dose  four  times  as  much.  In 
hyperacidity  and  hypersecretion  these  drugs  should  be  given  in 
large  and  repeated  doses  (see  Chapter  XIII) :  sodium  bicarbonate, 
4  to  8  Gm.  (oj-ij);  magnesium  oxid,  1  to  2  Gm.  (15  to  30  grains). 
A  soluble  aluminum  silicate,  capable  of  slowly  combining  with 
hydrochloric  acid,  is  sold  under  the  trade  name  neutralon.  It  is  a 
white,  odorless  and  tasteless  powder,  insoluble  in  water,  and  has 
been  found  useful  in  hyperchlorhydria,  hypersecretion,  and  gas- 
tric ulcer.  The  dose  is  one  teaspoonful  15  to  30  minutes  before 
meals. 

In  cases  of  gastric  ulcer  with  symptoms  of  hyperacidity  it  is 
advisable  to  avoid  the  carbon  dioxid  alkalis,  on  account  of  the 
gastric  distention  that  is  likely  to  follow  the  formation  of  gas. 

The  Carlsbad  salts  fulfil  indications  similar  to  those  for  the 
other  alkalis  mentioned.  Natural  crystalline  Carlsbad  sprudel 
salt  consists  (after  removal  of  the  water  of  crystallization)  of 
sodium  sulphate,  98.79;  sodium  carbonate,  0.45;  and  sodium 
chlorid,  0.76.  The  artificial  salts  (see  page  264)  are  similar  in 
their  effects;  but,  while  they  are  cheaper,  they  are  not  so  agreeable 
to  the  taste  as  the  natural  salts. 

Magnesia  magma  (milk  of  magnesia)  is  a  suspension  of  magnesium 
hydroxid  in  water.  A  dose  of  one-half  to  two  tablespoonfuls  will 
neutralize  the 'acid  in  hyperacidity,  and  will  act  favorably  when 
this  condition  is  complicated  with  constipation. 

In  cases  of  hyperacidity  the  proper  times  for  the  administration 
of  alkalis  are  directly  after  eating,  and  at  the  height  of  digestion 
when  the  secretion  of  acid  is  freest.  Patients  are  frequently  able 
to  tell  this  particular  moment  with  considerable  exactness,  as  it 
coincides  with  the  onset  of  their  painful  symptoms. 

In  the  absence  of  saliva,  jaborandi  or  pilocarpiii  can  be  given, 
since  these  drugs  are  known  to  be  sialagogues.  The  absence  of 
salivary  secretion  retards  amylolysis  greatly,  and  proteolysis  as 
well.  In  cases  of  such  pronounced  hyperacidity  that  salivary 
digestion  is  inhibited,  malt  diastase  combined  with  alkalis  acts 
well.  I  think,  however,  that  in  such  conditions  the  object  could 
be  better  accomplished  by  more  prolonged  mastication  and  insali- 
vation  of  the  food. 

Course  of  Medication. — The  course  of  medication  in  hyperchlor- 
hydria is  as  follows:     In  light  cases  the  attempt  is  made  with  alkalis 


438  SECRETORY  NEUROSES 

alone.  When  the  cases  are  more  obstinate  and  cause  much  dis- 
comfort, astringents  may  be  given  in  addition  to  the  alkalis. 
Severe  cases,  especially  those  with  excruciating  pains,  a  high  degree 
of  acidity,  and  pylorospasm,  require  the  administration  of  the 
alkaloids,  combined  with  alkalis  and  astringents. 

Lavage  of  the  Stomach. — In  cases  of  hyperchlorhydria  complicated 
with  atony  or  disturbances  in  motility,  lavage  of  the  stomach  is 
useful.  Lavage  may  be  performed  late  at  night  after  an  early 
supper,  or  early  in  the  morning.  It  should  be  followed  by  a  solu- 
tion of  Carlsbad  salt  or  a  1:1000  solution  of  nitrate  of  silver,  to 
be  washed  out  with  pure  water. 

Physiotherapeutic  measures  are  indicated  as  palliatives  in 
severe  cases  only,  where  something  must  be  done  at  once.  Hot 
compresses  over  the  region  of  the  stomach  mitigate  the  severity  of 
pain.  The  Leiter  coiled  tube  (Fig.  61)  has  a  quieting  and  anti- 
spasmodic action. 

In  chlorotic  patients,  when  iron  is  to  be  given,  I  prefer  the 
hypodermic  administration  of  the  citrate  of  iron,  as  described  on 
page  581. 

The  following  formulas  for  combinations  of  alkaline  medica- 
ments will  be  found  serviceable  in  various  conditions: 

Gm.  or  Cc. 
1$ — Sodii  bicarbonatis, 

Magnesii  oxidi aa      410  3  j 

Calcii  carbonatis 6[0  3iss 

Misce  et  ft.  pulv. 
Sig. — Take  one  teaspoonful  immediately  after  each  meal,  with  water.     The 
dose  may  be  repeated,  increased  or  diminished  as  required. 

Gm.  or  Cc. 

1$ — Magnesii  oxidi   . 10 10  3uss 

Sodii  bicarbonatis 40 1 0  3-x 

Misce  et  ft.  pulv. 
Sig. — One-half  to  one  teaspoonful  three  times  a  day,  one  or  two  hours  after 
meals,  in  half  a  glass  of  water. 

Gm.  or  Cc. 
1$ — Bismuthi  subnitratis, 

Magnesii  oxidi, 

Sodii  bicarbonatis aa     30 1 0  5  j 

Misce  et  ft.  pulv. 

Sig. — Heaping  teaspoonful  in  a  half-glass  of  water  one  hour  after  meals. 

Gm.  or  Cc. 

B — Magnesii  oxidi, 

Pulveris  radicis  rhei      ....  aa    2010  5v 

Sodii  bicarbonatis 40 1 0  3x 

Misce. 

Sig. — One-half  to  one  teaspoonful  in  water  one  or  two  hours  after  meals. 

For  hyperacidity  with  diarrhea : 

Gm.  or  Cc. 

B; — Cretse  prseparatse, 

Bismuthi  subgallatis, 

Sodii  bicarbonatis aa     10 10  Suss 

Misce  et  ft.  chart,  no.  xx. 

Sig. — One  powder  six  or  more  times  daily. 


H  YPERCIILORH  YDR1A 


|:i!) 


For  hyperacidity  with  pain: 


n 


Gm.  or  Cc. 


Codeinae  phosphatis 0  25 

Cretae  prseparatse 4  0 

Bismuthi  subnitratis 10  0 

Magnesii  oxidi 4  0 

Sochi  bicarbonatis 10  0 

Misc  et  ft.  chart,  no.  xv. 

Sig. — One  powder  to  be  taken  one  hour  after  meals. 


R — Cocainse  hydrochloridi 

Heroinse  hydrochloridi 

Atropinse  sulphatis 

Extracti  ergotae 

Aquae  destillatae 
Misce. 
Sig. — Five  to  twenty  drops  every  hour  until  relieved. 


Gm 
0 
0 
0 

1 

10 


or  Cc. 

10 

02 

01 

0 

0 


gr.  iv 

oj 

oiiss 
3j. 
oiiss 


gr.  iss 
gr-  § 
gr.  i 
gr.  xv 
3hss 


If  between  meals  there  is  burning  or  pain  in  the  stomach  due  to 
hyperchlorhydria,  Stockton's  gastric  sedative  formulae  are  useful 
(see  page  414). 


CHAPTER  XXL 

SECRETORY  NEUROSES  (Continued). 

Hypersecretion — Gastrorrhea — Gastrosuccorrhea — 
Gastrochtlorrhea. 

The  term  "gastrosuccorrhea"  was  introduced  into  medical 
literature  as  representing  a  clinical  entity  in  1882,  by  Reichmann. 
In  gastrosuccorrhea,  gastrorrhea,  or  hypersecretion,  the  glands  of 
the  stomach  secrete  gastric  juice  constantly;  considerable  amounts 
may  be  found  in  the  fasting  stomach,  before  the  first  meal  of  the  day. 
Opinions  vary  as  to  the  quantity  of  gastric  juice  that  indicates 
hyper  secretion.  The  percentage  of  hydrochloric  acid  may  or  may 
not  be  above  the  normal. 

INTERMITTENT  OR  PERIODIC  HYPERSECRETION  (ACUTE 
INTERMITTENT  GASTRORRHEA). 

Etiology. — In  ascertaining  the  cause  of  hypersecretion  we  must 
look  to  the  nervous  system.  Among  the  etiologic  factors  may  be 
a  derangement  in  the  vegetative  nervous  system,  manifested  in 
neurasthenia,  hysteria,  anger,  worry,  and  mental  overexertion. 
Young  adults  are  particularly  prone  to  attacks.  It  is  highly  prob- 
able that  chronic  hyperacidity  may  induce  acute  hypersecretion, 
especially  when  the  gastric  mucous  membrane  is  being  irritated. 
A  perfectly  healthy  mucous  membrane  with  habitually  normal 
secretion  may,  however,  produce  a  flow  of  hyperacid  gastric  juice 
on  the  ingestion  of  certain  articles  of  diet.  Very  cold  beverages 
may  occasion  hypersecretion.  Acute  hypersecretion  occurs  not 
infrequently  after  the  healing  of  gastric  ulcer;  the  exciting  cause 
is  presumed  to  be  the  cicatrix  of  the  ulcer. 

Symptoms.- — Hypersecretion  appearing  at  regular  intervals  is 
characterized  by  violent  pain  and  copious  vomiting  of  acid  materials. 
As  a  rule  the  seizures  are  sudden  and  not  anticipated  by  the  patient; 
they  occur  mostly  during  the  night  or  in  the  early  morning  hours. 
After  the  expulsion  of  food  remnants,  the  vomited  matter  consists 
of  varying  quantities  of  greenish  to  clear  watery  fluid  which  exhibits 
all  the  characteristics  of  gastric  juice.  The  chemical  tests  show 
the  presence  of  hydrochloric  acid  and  pepsin.  The  microscope 
indicates  the  presence  of  epithelial  cells  and  leukocytes.  The 
violent  pains,  together  with  the  retching  and  vomiting,  reduce 
the  patient  to  a  condition  of  exhaustion.  There  is  pronounced 
pallor,  perspiration  is  free,  and  the  pulse  is  feeble  and  rapid; 
appetite  fails,  and  the  bowels  are  torpid;  the  urine  is  scanty  and 
usually  alkaline  in  reaction.     The  attacks  may  be  of  great  severity, 


CONTINUOl  N  //  Yl'ERSECRETION  1  1 1 

or  they  may  be  very  slight;  their  duration  varies  from  one  or  two 
hours  to  as  many  days.  Convalescence  is  usually  rapid,  and  the 
patient  may  feel  well  enough  to  resume  his  occupation  the  day 

following  the  attack. 

Not  infrequently  the  seizures  are  accompanied  by  violent  head- 
aches. Attacks  in  which  headache  is  a  prominent  symptom  have 
been  designated  by  the  special  term  gastroxynsis;  they  belong, 
however,  to  the  class  of  intermittent  hypersecretion.  Sometimes 
the  cephalalgia  is  of  such  a  character  that  the  local  gastric  dis- 
turbance is  obscured.  The  patient  may  feel  perfectly  well  during 
the  interval  between  the  seizures;  slight  gastric  discomforts,  such 
as  pressure,  fulness,  eructations,  are,  however,  experienced  after 
eating.  An  examination  of  the  stomach  contents  during  the  interval 
between  attacks  shows  an  excessive  acidity,  which  would  indicate 
the  possibility  of  a  coexistent  chronic  hyperacidity. 

Diagnosis. — The  diagnosis  is  confirmed  by  emesis  of  large  quan- 
tities of  liquid  which  responds  to  the  tests  for  gastric  juice.  Analysis 
of  the  gastric  contents  yields  characteristic  results  (see  page  94). 

Treatment. — When  the  physician  is  called  during  an  acute  attack 
of  hypersecretion,  it  is  his  first  duty  to  cut  short  the  attack,  or, 
failing  in  this,  to  mitigate  its  severity.  At  its  onset  the  disease 
may  be  diminished  in  severity,  or  even  aborted,  by  the  administra- 
tion of  large  doses  of  sodium  bicarbonate  or  magnesium  oxid. 
Stomach  lavage  is  indicated  either  with  clear  water  or  with  water 
containing  nitrate  of  silver  (1:10,000).  The  drinking  of  milk  has 
sometimes  a  salutary  effect.  Should  the  attack  continue,  atropin, 
1  milligram  (g-1^-  grain),  is  indicated,  to  be  administered  hypoder- 
mically.  This  is  the  most  reliable  medicament.  Morphin  and 
atropin  may  be  combined  and  administered  subcutaneously. 
Suppositories  of  extract  of  belladonna  combined  with  morphin 
are  useful,  but  do  not  act  so  promptly  as  atropin  and  morphin 
hypodermically.  The  abdominal  pains  are  to  be  treated  with  hot 
compresses,  moist  or  dry.  Xo  food  should  be  taken.  Thirst  should 
be  allayed  by  small  pieces  of  ice  in  the  mouth.  In  the  absence  of 
distressing  symptoms  during  the  intervals  between  the  attacks, 
and  especially  if  the  secretion  of  hydrochloric  acid  is  normal,  a 
bland  diet  may  be  prescribed.  Irritating  food,  the  use  of  tobacco, 
and  excessive  mental  efforts,  should  all  be  avoided.  In  some  cases 
all  therapeutic  measures  fail  to  prevent  a  recurrence  of  the  attacks 
and  they  become  chronic.  In  the  treatment  of  nervous  patients 
suffering  from  chronic  hypersecretion,  favorable  results  are  fre- 
quently obtained  by  a  sojourn  in  a  high  altitude. 

CONTINUOUS  HYPERSECRETION  (CHRONIC  GASTRORRHEA). 

In  this  form  of  hypersecretion  the  stomach  secretes,  apparently 
spontaneously,  at  any  rate  without  the  stimulating  influence  of 


442  SECRETORY  NEUROSES 

food,  a  strong  digestive  juice,  and  that  continuously.  Normally 
only  a  few  milliliters  of  fluid  contents  are  found  in  the  fasting 
stomach,  and  pepsin  and  hydrochloric  acid  are  either  absent  alto- 
gether or  present  in  small  quantities.  In  cases  in  which  large  quan- 
tities of  gastric  juice  are  found  regularly  on  removing  the  contents 
of  the  stomach  after  prolonged  abstinence  from  food,  the  diagnosis 
of  chronic  gastrorrhea  is  confirmed. 

Etiology. — Chronic  hypersecretion  may  develop  from  a  pre- 
viously existing  hyperacidity,  which  explains  the  frequent  simul- 
taneous occurrence  of  both  disease  processes.  In  such  instances 
hypersecretion  is  an  aggravated  form  of  hyperacidity,  in  which 
the  secretory  and  sensitive  condition  of  the  mucous  membrane  is 
more  pronounced  than  in  cases  of  uncomplicated  hyperacidity. 
There  can  be  no  doubt  that  nervous  influences,  too,  constitute  an 
important  factor  in  the  causation  of  hypersecretion.  The  majority 
of  cases  of  chronic  hypersecretion  occur  in  youth  and  middle  age 
and  in  males.  The  secretion  of  gastric  juice  is  augmented  by  the 
abuse  of  alcohol  and  tobacco.  Among  the  causative  factors  are 
to  be  enumerated  dietetic  errors  and  mental  perturbations.  Gastric 
ulcer  is  also  a  cause  of  chronic  hypersecretion.  The  frequent 
coincidence  of  chronic  gastrorrhea  and  atony  of  the  stomach  is 
worthy  of  note.  There  is  also  the  possibility  of  a  relationship 
between  hypersecretion  and  the  traction  of  hernias  on  the  linea 
alba  and  traction  on  the  mesenteries  in  gastroenteroptosis.  Possible 
derangement  of  the  vegetative  nervous  system  must  not  be  over- 
looked (see  page  387) . 

Symptoms.— Chronic  hypersecretion  is  characterized  by  slow 
onset,  with  mild  symptoms,  pressure  and  fulness  after  eating, 
eructations,  and  pyrosis.  The  prodromes  are  those  of  chronic 
gastritis.  The  symptoms  may  disappear,  only  to  recur  in  aggra- 
vated form.  Pain  is  an  additional  symptom;  according  to  the 
statements  of  the  patient,  it  does  not  follow  the  ingestion  of  food. 
Pains  may,  however,  be  induced  by  partaking  of  food,  or  occur 
suddenly  at  irregular  intervals.  Thus  the  pain  of  hypersecretion 
differs  from  that  of  hyperacidity,  which  usually  comes  on  at  the 
height  of  digestion.  The  fact  that,  the  stomach  being  empty,  the 
ingestion  of  food  while  the  pain  is  most  severe  will  bring  relief,  is 
of  diagnostic  importance.  At  the  height  of  a  paroxysm,  vomiting 
frequently  occurs,  and  it  has  a  marked  effect  in  mitigating  the 
severity  of  the  pains.  The  greenish  watery  fluid  expelled  from 
the  stomach  may  amount  to  several  liters.  Hematemesis  is  some- 
times noted;  when  it  is  present,  gastric  ulcer  or  erosions  of  the 
stomach  should  be  borne  in  mind.  The  appetite  is  usually  fair, 
but  suffers  as  the  pains  become  more  persistent  and  severe.  The 
quantity  of  food  taken  by  the  patient  becomes  less  and  less,  with 
the  result  that  he  loses  weight  and  flesh.  In  pronounced  cases  of 
chronic  hypersecretion  the  patient  complains  of  thirst,  the  bowels 


CONTINUOUS  HYPERSECRETION  443 

are  constipated,  and  the  urine  is  turbid  from  a  slight  degree  6f 
alkalinity. 

Many  cases  of  hypersecretion  are  complicated  with  atony  and 
motor  insufficiency  of  the  stomach.  Such  cases  are  characterized 
by  the  vomiting  of  large  quantities  of  fluid. 

Diagnosis. — On  the  removal  of  the  stomach  contents  in  a  well- 
marked  case  of  hypersecretion  six  or  seven  hours  after  a  test  meal, 
large  quantities  are  found,  with  no  meat  remnants,  but  residues 
of  starchy  materials,  which  are  precipitated  to  the  bottom  of 
the  vessel.  The  total  acidity  of  the  material  removed  is  often 
high,  90  to  100,  and  free  hydrochloric  acid  is  increased  from  50  to 
70.  Sometimes,  especially  in  cases'  of  hypersecretion  accompanied 
by  dilatation  of  the  stomach,  the  contents  show  copious  evolution 
of  gas  in  the  fermentation  tubes  kept  in  the  incubator  (Fig.  15).  If 
the  stomach  be  carefully  cleansed  at  night  and  the  patient  instructed 
to  fast,  removal  of  the  stomach  contents  in  the  morning  will  show 
varying  quantities  of  liquid  secretion  (up  to  \  liter)  possessing  the 
properties  of  gastric  juice.  A  positive  finding  of  this  kind  serves  to 
confirm  the  diagnosis  of  hypersecretion  (see  page  94) . 

External  Examination  of  the  Stomach. — Palpation  reveals  an 
accelerated  peristaltic  motion.  A  thickened  pylorus  may  be 
sometimes  felt  by  the  palpating  hand,  inasmuch  as  the  pyloric 
exit  of  the  stomach  is  often  in  a  state  of  tetanic  contraction  induced 
by  the  large  quantity  of  acid  present.  As  soon  as  a  portion  of  the 
acid  stomach  contents  passes  through  into  the  small  intestine  the 
pylorus  closes,  so  that  it  is  impossible  for  the  stomach  to  properly 
empty  itself.  Each  relaxation  of  the  pylorus  is  followed  by  a  spasm 
which  blocks  the  exit  (pylorospasm) .  The  muscles  of  the  stomach, 
meanwhile,  attempt  to  force  a  passage  by  means  of  increased 
peristaltic  movements.  This  vicious  circle  is  the  cause  of  the 
gastric  dilatation  which  so  frequently  complicates  these  cases. 
Thickening  of  the  pylorus  may  be  the  result  of  an  old  cicatrix 
from  healing  of  a  gastric  ulcer  (see  page  479).  A  Roentgen-ray 
examination  assists  in  the  diagnosis. 

Prognosis. — The  prognosis  for  complete  recovery  from  chronic 
hypersecretion  is  not  always  favorable.  Recovery  may  be  antici- 
pated only  in  that  class  of  patients  who  are  in  a  position  to  continue 
treatment  for  a  long  period  of  time,  Patients  who  are  unable  to 
take  the  necessary  care  of  themselves  are  apt  to  have  relapses  after 
intervals  of  improvement. 

Treatment. — The  treatment  of  chronic  hypersecretion  is  clearly 
indicated  on  examination  of  the  contents  of  the  stomach,  and  by 
the  subjective  and  objective  symptoms.  Should  there  be  evidence 
of  any  other  pathologic  condition  complicating  or  maintaining 
the  hypersecretion,  this  must  receive  due  consideration.  If  gastric 
ulcer  is  present  it  must  receive  attention;  and  the  neurasthenic 
requires  special  treatment.     Patients  suffering  from  hyperacidity 


444  SECRETORY  NEUROSES 

should  be  so  treated  as  to  preclude  the  possibility  of  transforming 
that  condition  into  hyper  secretion.  Anger,  excitement,  mental 
shock,  and  improper  diet  should  be  avoided  as  much  as  possible. 
Frequently,  however,  hypersecretion  would  seem  to  be  an  idio- 
pathic disease,  one  for  which  there  is  no  assignable  cause. 

Diet. — The  chief  factor  in  the  therapeutics  of  hypersecretion  is 
a  properly  selected  dietary.  Since  the  quantity  of  gastric  juice 
secreted  during  the  period  of  digestion  is  abnormally  large,  prote- 
olysis is  likely  to  be  satisfactory.  This  is  attested  by  the  fact  that 
when  the  stomach  contents  are  removed  after  a  meal  of  meats 
and  starches,  scarcely  any  meat  remnants  remain;  the  residue  is 
made  up  principally  of  amylaceous  material.  The  gastric  digestion 
of  carbohydrates  is  held  completely  in  abeyance  in  hypersecretion, 
since  the  ptyalin  is  neutralized  almost  as  soon  as  the  food  reaches 
the  stomach.  From  this  it  follows  that  the  food  should  be  mainly 
protein.  So  far  as  the  quantity  of  fats  in  the  food  is  concerned, 
the  statements  regarding  fat  in  hyperacidity  hold  good.  Fat 
diminishes  the  secretion  of  hydrochloric  acid,  and  should  therefore 
be  employed  extensively  in  the  treatment  of  hypersecretion.  A 
diet  of  protein  and  fat  is  indicated.  The  gastric  mucous  membrane 
is  in  a  condition  of  chronic  irritation;  therefore,  in  prescribing 
diet,  care  must  be  exercised  to  avoid  articles  of  food  which  are  apt 
to  aggravate  this  condition.  All  spices,  acids,  and  highly  seasoned 
foods  must  be  eliminated  from  the  diet.  Extremes  of  temperature 
in  foods  and  beverages  should  be  avoided.  Thorough  mastication 
of  the  food  is  an  important  requirement;  the  food  should  be  in 
a  finely  subdivided  condition  before  being  swallowed. 

The  various  kinds  of  meat  may  be  taken  by  this  class  of  patients. 
Meats  should  be  well  cooked,  since  the  extractives  in  rare  meat 
excite  the  secretion  of  still  greater  quantities  of  gastric  juice.  Soft- 
boiled  eggs,  scrambled  eggs,  omelet,  and  cream  cheese  are  indicated. 
Of  fats,  numerous  articles  merit  consideration;  for  example,  butter, 
olive  oil,  sesame  oil,  cottonseed  oil,  milk  and  cream,  cocoa,  and  yolk 
of  egg.  Milk  is  an  excellent  liquid  food;  it  is  non-irritant  and  has 
a  neutralizing  effect  upon  the  acidity  of  the  gastric  juice. 

Carbohydrates,  for  obvious  reasons,  should  be  restricted  unless 
they  have  been  dextrinized;  wheat  bread  should  be  eaten  in  the 
form  of  toast.  Crackers  and  zwieback  are  suitable  articles  of  diet.. 
Carbohydrates  should  be  given  in  the  form  of  leguminous  flour 
soups,  or  gruels,  or  as  sago  and  oatmeal.  The  patient  may  partake 
of  a  small  quantity  of  mashed  potatoes.  All  green  vegetables 
should  be  prohibited.  Sugar  is  allowable  only  in  cases  in  which 
the  motility  of  the  stomach  is  normal,  since  it  may  give  rise  to 
excessive  fermentation.  Care  should  be  exercised  in  the  preparation 
of  dishes  for  this  class  of  patients,  to  avoid  even  a  moderate  use 
of  condiments. 


CONTIA  ( 'OUS  II  YPERSECRETION  I  15 

Number  of  Meals.-  Regarding  the  number  of  meals,  a  good 
rule  to  follow  is:     Eat  often,  and  a  little  at  a  time.     The  object  is 

to  take  up  tin'  gastric  juice  as  fast  as  it  is  secreted.  Frequent 
administration  of  food  will  tend  to  bring  about  an  entire  cessation 
of  pain;  suitable  articles  of  food  should  be  at  hand  all  the  time. 
Milk,  biscuits,  and  hard-boiled  eggs  should  be  easily  accessible  to 
the  patient  on  retiring  at  night;  these  taken  at  the  beginning  of  a 
pain  will  often  suppress  it. 

Li 1 1 u ids. — Liquids  should  be  taken  in  moderation,  since  they 
tend  to  increase  the  quantity  of  fluid  in  the  stomach.  They  are 
particularly  harmful  in  cases  of  hypersecretion  combined  with 
atony  or  dilatation.  Alcohol  and  coffee  should  be  avoided.  When 
there  is  great  thirst,  and  it  is  inadvisable  to  partake  of  sufficient 
liquid  by  mouth  to  allay  the  thirst,  a  small  enema  (150  Cc.)  of 
physiologic  salt  solution  will  satisfy  the  craving. 

In  severe  cases  of  hypersecretion  it  is  sometimes  advisable  to 
resort  to  rectal  feeding  for  a  period  of  eight  to  ten  days  (see  page  243) . 
By  this  means  irritation  of  the  stomach  by  food  will  be  obviated, 
and  a  diminished  secretion  of  gastric  juice  will  result.  An  exclu- 
sive milk  diet  for  eight  to  ten  days  is  very  beneficial;  this  is  what  is 
called  the  "milk  cure."  The  milk  diet  acts  as  a  sedative  to  the 
sensory  nerve  endings  in  the  gastric  mucous  membrane.  Inter- 
current diarrheas  may  be  prevented  by  the  addition  of  lime-water 
to  the  milk  in  the  proportion  of  1  to  3  or  1  to  4.  The  feedings 
should  consist  of  350  to  400  Cc.  (12  to  14  ounces)  of  milk  every 
two  hours,  or  a  daily  amount  of  2800  Cc.  (about  3  quarts).  The 
required  number  of  calories  may  be  attained  by  the  addition  of  a 
milk-cream  mixture. 

In  cases  of  hypersecretion  with  pylorospasm,  the  continuous 
saline  instillation — the  Murphy  drip  (see  page  239) — to  restore  the 
needed  water  to  the  tissues,  is  beneficial.  This  treatment  has  a 
distinctly  favorable  influence  on  the  spasm,  promoting  relaxation, 
as  evidenced  by  the  cessation  of  vomiting.  Systematic  continuous 
proctoclysis,  as  a  direct  means  of  influencing  the  pylorospasm  in 
addition  to  its  other  advantages,  is  recommended. 

Medicinal  Treatment. — The  alkalis  are  valuable  therapeutic 
agents  in  the  treatment  of  hypersecretion,  as  well  as  in  hyper- 
acidity. They  may  be  prescribed  to  be  taken  before,  during,  or 
after  the  ingestion  of  food.  Given  during  or  before  a  meal,  they 
are  calculated  to  facilitate  amylolysis,  since  they  neutralize  the  free 
hydrochloric  acid  which  would  otherwise  put  a  stop  to  the  action 
of  the  ptyalin  of  oral  digestion  as  soon  as  it  reached  the  stomach. 

Alkalis  are  given  after  meals  to  neutralize  excessive  acidity 
that  is  producing  painful  symptoms.  Large  doses  have  the  effect 
of  immediately  relieving  the  pain.  They  are  valuable  for  allaying 
the  violent  paroxysmal  nocturnal  pains  of  hypersecretion,  but 
unfortunately  the  relief  is  not  permanent.     Magnesium  oxid  and 


446  SECRETORY  NEUROSES 

sodium  bicarbonate  are  particularly  useful  in  these  conditions. 
The  administration  of  the  Carlsbad  salt  in  the  morning  after  the 
night's  fast  is  a  useful  procedure,  since  it  neutralizes  the  gastric 
secretion  and  washes  it  into  the  duodenum  (see  page  264) . 

For  the  improvement  of  amylolysis,  artificial  salivary  ferments 
have  been  employed.  One  of  these  is  an  artificial  ptyalin.  This 
preparation  may  be  given  with  the  alkalis.  Again,  we  have  taka- 
diastase  and  malt  diastase;  these  act  in  the  same  way  as  ptyalin. 
Taka-diastase  may  be  prescribed  to  be  taken  with  the  food,  with 
or  without  alkalis,  in  cases  of  hyperacidity  and  hypersecretion. 
Panase  is  a  pancreatic  preparation  similar  in  its  action. 

Atropin  sulphate,  1  milligram  (^q-  grain),  has  been  given  hypo- 
dermically  during  violent  attacks  of  pylorospasm.  The  object  is 
to  restrict  the  secretion.  In  many  cases  the  following  treatment, 
kept  up  for  fourteen  days,  will  be  sufficient  to  effect  a  permanent 
cure: 

6m.  or  Cc. 

IV— Atropinse  sulphatis 0 1 0005-0 1 001    gr.  ^hnsis 

Misce. 

Sig. — For  subcutaneous  injection  three  times  a  day,  and  always  by  the 
physician  himself. 

The  contra-indications  are  affections  of  the  heart  and  blood- 
vessels. If  accommodation  paresis,  dry  sensation  in  the  throat, 
and  vertigo  are  not  very  severe,  the  treatment  may  be  continued. 
A  test  for  the  applicability  of  the  atropin  treatment  consists  in  giv- 
ing on  two  succeeding  days  0.0005  or  0.001  Gm.  (T-f-g  to  -^  grain) 
of  atropin  subcutaneously  shortly  before  the  test  breakfast.  If,  on 
examination,  the  secretion  is  found  to  have  diminished,  the  treat- 
ment is  indicated.  Eumydrin  also  can  be  used,  and  is  safer.  Favor- 
able results  have  been  secured  from  the  use  of  extract  of  belladonna 
in  suppository  form.  This  drug  may  also  be  given  internally,  either 
alone  or  in  combination  with  the  alkalis  (see  page  271). 

Astringent  remedies  are  to  be  employed  as  in  the  treatment  of 
hyperacidity.  Preparations  of  bismuth  or  nitrate  of  silver  may  be 
given  by  mouth  (see  pages  265  and  267). 

Lavage  of  the  Stomach.- — When  the  symptoms  do  not  yield  to  diet 
or  drugs,  the  stomach  should  be  washed  out  just  before  the  evening 
meal;  it  is  then  in  a  condition  to  receive  and  to  digest  a  small 
supper.  The  acid  secreted  after  the  supper  is  neutralized  by  the 
food.  Lavage  is  also  indicated  in  the  morning  before  breakfast, 
to  remove  the  acid  secreted  during  the  early  morning  hours,  as 
well  as  the  remnants  of  food  that  may  have  remained  overnight 
in  the  stomach.  In  pronounced  cases  of  hypersecretion,  lavage 
at  these  two  periods  is  imperative;  painful  attacks  are  often  cut 
short  by  a  single  washing.  Pure  water,  lukewarm,  is  employed  in 
the  process,  to  be  followed  by  lavage  with  a  mild  alkali,  such  as 
sodium  bicarbonate  solution.  Lavage  with  1 :  10,000  nitrate  of  silver 
or  with  a  suspension  of  bismuth  subnitrate  has  been  employed  with 
good  success. 


ALIMENTARY  HYPERSECRETION  447 

Mineral  Water*,  Carlsbad  water,  taken  in  large  doses  and  for 
a  long  period  of  time,  has  the  effect  of  diminishing  the  secretion  of 
gastric  juice.  It  is  favorable  to  the  peristaltic  movements  of  the 
stomach,  and  tends  to  diminish  the  sensitiveness  of  that  organ. 
The  waters  of  Saratoga  are  similar  in  action  to  the  Carlsbad  waters 
(see  Chapter  XII).  Vichy  water  may  be  prescribed  for  neurotic 
patients. 

Physical  Treatment. — Massage,  vibration,  and  electric  treatment 
must  not  be  employed  in  hypersecretion.  Hydrotherapeutic  and 
thermic  applications  may,  however,  be  made  extensively  and  to 
good  advantage.  Hot  compresses,  moist  or  dry,  are  particularly 
adapted  to  the  treatment  of  painful  seizures.  In  severe  cases 
prolonged  rest  in  bed  is  essential. 

Surgical  Treatment. — In  cases  of  hypersecretion  complicated 
with  ulcer  of  the  pylorus  or  duodenum,  marked  motor  disturbances 
and  stenosis  of  the  pylorus,  gastroenterostomy  may  prove  of 
permanent  benefit. 

ALIMENTARY  HYPERSECRETION. 

Alimentary  hypersecretion  is  a  less  severe  variety  of  chronic 
gastrorrhea.  While  in  chronic  gastrorrhea  the  gastric  mucous 
membrane  is  in  a  state  of  continuous  irritability,  as  a  result  of 
which  the  gastric  secretion  is  constant  and  abnormal  in  quantity, 
even  when  the  stomach  is  empty,  in  alimentary  hypersecretion 
the  symptoms,  which  afford  the  same  clinical  picture  when  they 
appear,  are  induced  only  by  stimulation  of  the  gastric  mucous 
membrane.  There  must  be  a  stimulus,  however  slight,  before  the 
abnormal  secretion  begins.  Much  less  stimulation  is  required, 
however,  than  in  the  normal  stomach;  the  secretion  begins  sooner. 

Symptoms. — The  subjective  symptoms  are  less  severe  than  those 
of  chronic  gastrorrhea,  resembling  more  closely  those  of  hyper- 
acidity. Gastric  discomforts,  consisting  of  pyrosis,  pressure,  acid 
eructations,  and  pain  of  greater  or  less  severity,  follow  almost 
immediately  the  ingestion  of  food;  whereas  in  hyperacidity  these 
symptoms  do  not  appear  until  some  little  time  after  eating.  In 
contrast  with  hyperacidity,  the  discomforts  of  alimentary  hyper- 
secretion are  not  diminished  by  partaking  of  food.  The  appetite 
is  usually  good,  though  patients  often  become  poorly  nourished 
because  they  are  afraid  to  eat.  When  alimentary  hypersecretion 
is  complicated  with  motor  disturbances,  the  distressing  symptoms 
persist  wrhile  the  food  remains  in  the  stomach.  With  intense 
attacks  of  gastric  pain,  as  in  chronic  gastrorrhea,  constipation  is 
a  frequent  concomitant  symptom. 

Diagnosis. — Palpation  of  the  empty  stomach,  as  a  rule,  does  not 
reveal  anything  of  note.  When  the  stomach  is  filled  with  food, 
palpation  occasionally  causes  a  slight  degree  of  pain.    Splashing 


448  SECRETORY  NEUROSES 

sounds  can  be  elicited  occasionally  during  the  height  of  digestion, 
especially  if  atony  be  present.  The  diagnosis  must  be  made  by 
means  of  the  test  meal  or  test  breakfast.  The  facts  that  the  fluid 
portion  exceeds  the  solid  residues,  and  that  the  total  quantity  of 
fluid  removed  is  greater  than  the  amount  introduced,  are  of  diag- 
nostic importance.  The  quantity  of  free  hydrochloric  acid  will 
be  found  above  normal.  There  are  no  pathologic  findings  which 
can  be  said  to  be  pathognomonic  of  this  disease. 

Treatment. — The  dietetic  treatment  is  the  same  as  that  pre- 
scribed for  chronic  gastrorrhea.  Owing  to  the  fact  that  amylolysis 
is  deficient,  the  food  should  be  chiefly  of  a  protein  and  fatty  nature. 
It  should  be  finely  subdivided,  preferably  mucilaginous  in  con- 
sistency; and  the  meals  should  be  limited  to  three  a  day  and  taken 
at  regular  intervals,  in  order  to  prevent,  to  the  greatest  possible 
extent,  irritation  of  the  gastric  mucous  membrane.  In  these  cases, 
too,  it  is  sometimes  expedient  to  place  the  patient  on  an  exclusive 
milk  diet,  keeping  him  in  bed. 

Medicinal  Treatment. — Alkalis  are  to  be  employed  extensively, 
both  before  and  during  meals,  to  assist  amylolysis,  and  also  after 
meals  at  the  height  of  digestion.  Atropin  sulphate,  hypodermically, 
by  mouth,  or  by  suppository,  is  of  value  when  there  is  pain.  Occa- 
sionally it  is  necessary  to  continue  the  administration  of  atropin 
over  an  extended  period.     Astringents  are  also  indicated. 

Treatment  by  Lavage  of  the  Stomach. — The  best  time  for  this 
procedure  in  cases  of  alimentary  hypersecretion  is  late  at  night, 
after  an  early  supper,  in  order  to  relieve  the  stomach  of  food  rem- 
nants and  thus  prevent  gastric  secretion  during  the  night.  Lavage 
with  pure  water  may  be  succeeded  by  lavage  with  alkalis  or  with 
nitrate  of  silver  (1:10,000). 


CHAPTER  XXII. 

ACUTE  GASTRITIS— SIMPLE,  INFECTIOUS,  TOXIC, 
PHLEGMONOUS. 

A.CUTE  gastritis  (acute  gastric  catarrh)  is  an  inflammation  of 
the  gastric  mucous  membrane  accompanied  by  disturbances  of 
digestion.  The  inflammation  may  be  simple,  infectious,  toxic  or 
phlegmonous.  It  may  be  limited  to  the  superficial  layer  of  the 
gastric  mucosa,  or  it  may  involve  the  glandular  epithelium,  the 
parenchyma,  or  the  interstitial  tissues. 

SIMPLE  ACUTE  GASTRITIS. 

This  is  the  form  that  is  most  frequently  encountered  in  general 
practice.     No  age  or  class  is  exempt. 

Etiology. — Among  the  etiologic  factors  are:  errors  in  diet — an 
excessive  amount  of  food  taken  at  one  time;  mechanical,  thermic 
or  chemical  irritants;  foods  highly  spiced  or  fermented;  unripe  or 
overripe  fruits;  cold  drinks,  soda  water  and  ice-cream;  food  in 
process  of  decomposition;  the  excessive  use  of  condiments;  and 
overindulgence  in  alcohol. 

The  tendency  to  acute  gastritis  is  greater  in  some  individuals 
and  families  than  in  others.  In  many  persons  the  predisposition 
is  such  that  the  slightest  excess  in  diet  precipitates  the  catarrhal 
condition.  In  this  class  are  anemic  women,  invalids,  and  elderly 
persons.  Acute  gastritis  may  be  secondary  to  other  affections,  as 
the  acute  infectious  diseases,  typhoid,  variola,  pneumonia,  or 
measles. 

Toxic  gastritis  in  its  milder  forms  may  be  placed  in  the  category 
of  simple  acute  gastritis.  Decomposition  products,  such  as  spoiled 
food,  meat  or  cheese,  are  contributory  to  this  form  of  gastric 
catarrh.  With  acute  gastritis  may  be  classed  the  light  forms  of 
acute  infectious  gastritis  caused  by  microorganisms  introduced 
with  decomposed  food.  It  is  well  known  that  parasites,  oxyurids, 
tenia?,  ascarides,  and  larvae  of  flies,  taken  into  the  stomach,  may 
cause  gastritis. 

Pathology. — The  gastric  mucosa  is  wholly  or  partially  swollen 
and  reddened,  the  inflamed  portions  covered  with  tenacious  mucus. 
In  occasional  instances  there  are  slight  hemorrhages.  The  sub- 
mucosa  may  be  edematous.  Microscopically,  the  surface  epithelium 
appears  altered;  it  is  swollen,  opaque  and  desquamated.  Similar 
changes  are  noted  in  the  glandular  epithelium.  The  capillaries 
29 


450  ACUTE  GASTRITIS 

are  markedly  dilated  and  congested.  Round-celled  infiltration  is 
occasionally  found  in  the  interstitial  tissue.  Examination  of  the 
stomach  contents  yields  characteristic  results  (see  page  95). 

Symptoms. — In  mild  forms  of  gastric  catarrh  due  to  dietetic 
errors  the  patients  complain  of  a  feeling  of  weight  in  the  pit  of  the 
stomach,  followed  by  a  sensation  of  fulness.  Belching  affords 
relief.  In  some  cases  there  is  nausea  and  in  the  more  severe  type 
of  acute  gastritis  the  onset  of  the  disorder  is  characterized  by 
gastric  pains,  nausea  and  vomiting,  rise  of  temperature,  loss  of 
appetite,  and  constipation  or  diarrhea.  The  vomited  material 
usually  consists  of  ill-smelling  and  fermented  masses,  acid  in  reac- 
tion; its  total  acidity  varies,  and  as  a  rule  there  is  either  no  free 
hydrochloric  acid  at  all  or  less  than  normal.  On  the  other  hand, 
there  may  be  hyperacidity  and  hypersecretion  accompanied  by 
pyrosis..  A  high  total  acidity  is  occasionally  caused  by  the  pres- 
ence of  the  organic  acids — acetic  and  butyric.  Emesis,  or  retch- 
ing after  the  stomach  has  been  emptied,  often  results  in  the  evacu- 
ation of  mucobiliary  masses.  The  tongue  is  coated  and  the  breath 
fetid.  The  region  over  the  stomach  is  sensitive  to  pressure,  and 
the  stomach  itself  is  slightly  distended.  Acute  gastritis  may  be 
afebrile,  or  there  may  be  a  temperature  of  102°  to  104°  F. 

Course.- — The  course  of  acute  gastritis  depends  largely  upon  the 
intensity  of  the  attack;  its  usual  duration  is  from  one  to  three 
days.  An  early  emesis  gives  great  relief,  so  that  the  distressing 
symptoms  often  rapidly  subside.  Sometimes,  however,  vomiting 
is  followed  by  lassitude,  weakness,  and  cephalalgia.  Acute  gastric 
catarrh  may  pass  from  the  stomach  to  the  intestine,  involving 
both,  so  that  we  have  a  gastroenteritis.  Though  patients  usually 
recover  from  mild  attacks  in  two  or  three  days,  the  so-called  "  weak 
stomach"  remains  and  the  patient  has  more  or  less  prolonged 
periods  of  anorexia. 

Prophylaxis. — Persons  subject  to  attacks  of  acute  gastric  catarrh 
should  be  on  their  guard  against  dietary  indiscretions.  They 
should  avoid  rich  food,  food  that  is  either  too  cold  or  too  hot, 
unripe  fruits,  and  whatever  may  have  been  implicated  in  causing 
previous  attacks.  Were  patients  to  avoid  such  articles  of  diet 
and  refrain  from  habits  and  excesses  known  to  themselves  to  be 
causative  factors  in  acute  gastric  catarrh,  the  occurrence  of  this 
disease  could  be  prevented  to  a  very  marked  degree. 

Treatment.  To  get  rid  of  the  undigested  material,  the  stomach 
empties  itself  by  vomiting,  or  by  passing  the  contents  on  to  the 
small  intestine,  where  they  may  set  up  a  diarrheal  discharge. 

"When  vomiting  does  not  take  place  from  the  irritation  caused 
by  the  mass  of  undigested  food  in  the  stomach,  we  should  lend  our 
assistance  to  bringing  about  evacuation  of  the  stomach  contents. 
The  best  method  of  cleansing  the  stomach  is  by  the  use  of  the 
stomach  tube.     Since  the  object  is  not  medication,  but  simply 


SIMPLE  ACUTE  GASTRITIS  451 

mechanical  elimination,  it  is  sufficient  to  wash  out  the  stomach 
with  lukewarm  water  to  which  sodium  bicarbonate,  a  teaspoonl'ul 
to  the  pint,  has  been  added.  This  will  promote  the  solution  of 
mucus.  I  strongly  commend  the  use  of  the  stomach  tube  for 
promptness  and  thoroughness  in  the  evacuation  of  the  stomach; 
it  has  the  additional  advantage  that  it  does  not  irritate  the  gastric 
mucosa  as  do  emetics  given  by  mouth.  In  performing  lavage,  the 
patient  should  be  instructed  to  assume  different  positions  to  facili- 
tate the  thorough  cleansing  of  the  stomach.  Usually  a  single 
la\age  is  sufficient  if  it  be  thoroughly  done.  In  children,  lavage 
is  the  only  method  of  cleansing  the  stomach  that  should  be  con- 
sidered. In  infants  and  very  young  children  it  may  be  accom- 
plished by  means  of  a  Nelaton  catheter. 

After  lavage  the  retching  ceases  and  the  general  condition 
improves.  It  is  evident  that  gastritis  cannot  be  cured  so  long 
as  decomposed  food  remains  in  the  stomach.  Emetics  proper  are 
reserved  for  those  cases  in  which,  for  one  or  another  reason,  it  is 
impossible  or  impracticable  to  use  the  stomach  tube.  The  most 
useful  emetic  is: 

Gm.  or  Cc. 

1$ — Antimonii  et  potassii  tartratis      .  0 1 05  gr.  j 

Pulveris  radicis  ipecacuanhae  ...       l|00  gr.  xv 

Misce  et  ft.  pulv.  no.  v. 
Sig. — One  powder  every  quarter  of  an  hour  until  vomiting  occurs. 

The  following  may  be  administered  to  children: 

Gm.  or  Cc. 
1$ — Pulveris  radicis  ipecacuanhae  ...       2|0  5ss 

Syrupi  amygdalae 20  [0  3v 

Misce. 

Sig. — One  dessertspoonful  every  ten  minutes  until  vomiting  is  induced. 

When  the  administration  of  emetics  by  mouth  is  inadvisable, 
on  account  of  its  tendency  to  increase  the  irritable  condition  of 
the  stomach,  the  hypodermic  injection  of  apomorphin  is  useful. 
Hypodermic  tablets  of  apomorphin  ready  for  use  are  to  be  had, 
and  fresh  supplies  should  be  carried  in  the  regular  medicine  case. 
The  action  of  apomorphin  is  rapid  and  certain. 

After  the  stomach  has  been  thoroughly  emptied  and  cleansed, 
all  food  should  be  interdicted  for  the  next  twenty-four  to  forty- 
eight  hours.  This  edict  will  not  be  difficult  to  enforce,  since  the 
patients  have  little  or  no  appetite.  Thirst  may  be  allayed  by 
means  of  cracked  ice.  Carbonated  waters,  iced  milk,  brandy  and 
soda,  and  lemonade  are  acceptable  and  generally  harmless. 

Preparations  containing  menthol  quiet  and  anesthetize  the 
hypersensitive  mucosa,  acting  at  the  same  time  as  antiseptics: 

Gm.  or  Cc. 

1^— Mentholis 1|0  gr.  xv 

Alcoholis, 

Syrupi aa     30|0  5j 

Misc. 

Sig. — One  teaspoonful  every  hour. 


452  ACUTE  GASTRITIS 

Validol  is  a  good  substitute  for  menthol.  It  is  a  preparation 
of  menthol  and  valerianic  acid,  containing  about  30  per  cent,  of 
free  menthol.  It  may  be  prescribed  to  be  taken  three  times  a  day 
in  doses  of  0.6  to  1  Cc.  (10  to  15  minims). 

Bicarbonate  of  sodium,  either  alone  or  with  such  antizymotics 
as  resorcinol  and  salicylic  acid,  may  be  given,  should  the  contents 
of  the  stomach  be  markedly  acid : 

Gm.  or  Cc. 
R — Resorcinolis 0 1 6  gr.  x 

Sodii  bicarbonatis, 

Bismuthi  salicylatis aa      4 1 0  3j 

Misce  et  ft.  pulv.  no.  x. 

Sig. — One  powder  every  two  hours. 

The  coated  tongue  may  be  nicely  cleansed  by  means  of  a  clean 
piece  of  soft  linen  moistened  with  lemon  juice. 

A  marked  degree  of  pyrosis  can  be  relieved  by  the  following: 

Gm.  or  Cc. 
R — Magnesii  oxidi, 

Sodii  bicarbonatis, 

Olei  sacchari  menthae  piperitae      .   aa     10 1 0  oijss 

Misce  et.  ft.  pulv. 
Sig. — One-quarter  of  a  teaspoonful  in  water  every  two  hours. 

For  the  relief  of  pain: 

Gm.  or  Cc. 

R — Codeinse  phosphatis 0 1 12  gr.  ij 

Aquae  menthse  piperitse      ....     30 1 0  B  j 

Misce. 
Sig. — One  teaspoonful  twice  or  three  times  a  day. 

For  acid  eructations: 

Gm.  or  Cc. 

R — Resorcinolis 1 1 0  gr.  xv 

Aquae  destillatae, 

Aquse  menthse  piperitse  .   aa     45 1 0  §  iss 

Misce. 
Sig. — One  teaspoonful  every  two  hours. 

Diet. — After  twenty-four  to  forty-eight  hours'  rest,  liquid  food 
(no  other)  should  be  given — soups  and  gruel  in  small  but  gradually 
increasing  quantities.  The  yolk  of  an  egg  may  be  added  to  the 
soup.  Later,  this  diet  may  be  followed  by  milk  sipped  slowly, 
fowl,  minced  ham,  crackers,  eggs,  and  fillet  of  beef.  This  is  usu- 
ally sufficient  for  an  ordinary  case  of  simple  acute  gastritis. 
Should  the  appetite  continue  poor,  it  may  be  stimulated  by 
hydrochloric  acid  dilute,  1  Cc.  (15  minims)  before  meals,  in 
lemonade  or  compound  tincture  of  cinchona.  Fluidextract  of 
condurango,  1  Cc.  (15  minims)  three  times  a  day,  before  meals, 
has  a  good  effect. 

Pain  is  sometimes  complained  of,  though  it  is  rarely  of  such 
intensity  as  to  require  treatment.  Moderate  pains  and  gastric 
pressure  are  best  treated  by  hydriatic  measures.  A  Priessnitz 
bandage,  renewed  every  two  or  three  hours,  is  of  good  service 


ACUTE  INFECTIOUS  GASTRITIS  453 

in  such  cases  (see  page  250).  Should  the  pains  be  more  severe, 
moist  applications  or  hot  dry  compresses,  hot  bottles  or  the  elec- 
tric pad  are  indicated.  These  appliances  may  be  continued  for 
some  time  if  necessary.  The  consideration  of  analgesic  and  nar- 
cotic remedies  must  be  reserved  for  cases  accompanied  by  excessive 
pain;  these  drugs  must  not,  however,  be  given  by  mouth,  but 
should  be  administered  in  suppository  form  only.  Extract  of 
opium,  0.03  to  0.05  Gm.  (|  to  1  grain);  codein  phosphate  in  the 
same  dose;  extract  of  belladonna,  0.03  Gm.  (|  grain) — these, 
alone  or  in  combination,  are  the  drugs  employed.  Morphin  is 
apt  to  induce  vomiting. 

The  intestinal  tract  may  be  affected  in  acute  gastric  catarrh 
by  the  presence  of  irritating  substances  from  the  stomach,  so 
that  instead  of  a  simple  acute  gastritis  we  have  an  acute  gastro- 
enteritis. "When  there  is  reason  to  suspect  the  presence  of  decom- 
posed and  irritating  masses  in  the  intestine,  it  is  good  treatment 
to  induce  evacuation.  Calomel  is  the  best  remedy  we  have  for 
this  purpose.  It  is  an  excellent  remedial  agent  in  the  treatment 
of  gastro-intestinal  disorders  of  children.  The  dose  for  adults  is 
0.12  Gm.  (2  grains)  twice  a  day,  or  0.01  Gm.  (f  grain)  every  hour 
for  ten  doses.  Castor  oil  is  also  a  useful  evacuant.  Patients  who 
cannot  take  castor  oil  will  readily  take  Rochelle  salt,  4  Gm.  (5j) 
in  a  half-glass  of  water;  it  should  be  taken  in  the  morning  when 
the  stomach  is  empty.  After  thorough  evacuation  of  the  bowels, 
three  or  four  days  may  be  allowed  to  elapse  before  the  next  move- 
ment. Should  constipation  persist,  an  enema  of  warm  water,  plain 
or  containing  soap,  oil,  glycerin,  vinegar,  soda  or  cottonseed  oil, 
should  be  given.  After  cleansing  the  intestine,  such  intestinal 
antiseptics  as  resorcinol  or  salicylate  of  bismuth  may  be  considered. 

ACUTE  INFECTIOUS  GASTRITIS. 

Gastric  catarrh  may  occasionally  assume  what  is  known  as  the 
grave  forrri. 

Etiology. — Usually  the  exciting  cause  of  infectious  gastric  catarrh 
consists  of  microorganisms  introduced  into  the  stomach  with 
articles  of  food,  decomposed  meat  or  fruit,  or  food  or  drink  which 
may  not  appear  to  be  tainted,  such  as  impure  milk,  or  water  from 
infected  wells.  The  grave  form  of  acute  gastric  catarrh  may  thus 
become  epidemic.  It  is  often  a  very  difficult  matter  to  determine 
with  absolute  certainty  the  cause  of  this  disease. 

Pathology. — The  pathologic  changes  accompanying  all  forms  of 
acute  gastritis  are  similar  to  those  of  the  mild  form;  the  difference 
is  one  of  degree  only.  There  is  marked  hyperemia,  tumefaction 
and  reddening  of  the  gastric  mucosa,  in  which  the  glandular 
epithelium  and  interstitial  tissue  participate.  There  is  also  emigra- 
tion of  wandering  cells  from  the  blood — leukocytes,  more  or  less 


454  ACUTE  GASTRITIS 

fibrin — which,  in  addition  to  the  acute  edema  of  simple  "gastritis," 
gives  the  histologic  picture  of  an  essential  inflammation.  Fre- 
quently there  are  small  petechial  hemorrhages. 

Symptoms. — The  symptoms  described  in  the  section  on  Acute 
Gastric  Catarrh  are  present  here  in  aggravated  form,  consisting 
of  violent  pains  accompanied  by  persistent  and  severe  vomiting 
and  marked  prostration.  Fever,  usually  absent  in  mild  gastric 
catarrh,  is  a  constant  symptom  of  the  grave  variety.  In  fact, 
the  febrile  disturbance  is  a  fairly  reliable  index  of  the  gravity  of 
the  disease.  These  severer  forms  of  acute  gastritis  are  some- 
times due  to  dietary  indiscretions;  but  they  are  more  frequently 
the  result  of  infection,  so  that  this  form  of  the  disease  is  desig- 
nated acute  infectious  gastric  catarrh. 

The  fever  (gastric  fever)  is  of  marked  intensity  and  of  the  con- 
tinued or  remittent  type.  Other  symptoms  are:  violent  throbbing 
headache,  insomnia,  thirst,  rapid  pulse,  and  occasional  delirium. 
In  the  febrile  cases  there  is  a  marked  diminution  of  acid  secretion; 
the  fever  itself  in  all  probability  reduces  the  secretion  of  hydro- 
chloric acid.  The  disease  ordinarily  runs  from  ten  to  fourteen 
days;  in  some  instances  the  fever  may  persist  for  three  weeks. 
In  very  old  and  very  young  patients  this  form  of  gastritis  may 
assume  an  alarming  character. 

The  severe  forms  of  infectious  gastritis  exhibit  clinical  symp- 
toms similar  to  those  that  are  caused  by  the  introduction  into 
the  stomach  of  organic  poisons,  such  as  the  metabolic  products 
of  infectious  microorganisms — toxins  and  ptomains.  The  course 
of  the  disease  is  usually,  but  not  always,  severe. 

Treatment. — The  treatment  of  these  severe  forms  of  acute  gastric 
catarrh  is  based  upon  the  same  principles  as  that  of  the  milder 
forms.  The  stomach  must  be  emptied  and  cleansed  as  quickly 
and  thoroughly  as  possible  by  means  of  lavage.  When  the  disease 
is  due  to  infection  it  is  well  to  wash  out  the  stomach  with  anti- 
septic solutions;  for  example,  salicylic  acid  1  to  2  parts  in  1000  of 
water,  or  dilute  boric  acid  solution  (3  :  1000  to  5  :  1000).  Emetics 
should  not  be  employed  if  it  is  possible  to  empty  the  stomach  in 
any  other  way.  Food  should  be  interdicted  for  a  number  of  days 
in  the  case  of  robust  patients,  to  give  the  stomach  needed  rest. 
Thirst  and  persistent  vomiting  are  to  be  met  by  small  doses  of  cold 
mineral  waters,  carbonated  waters  either  with  or  without  fruit 
juices,  cracked  ice,  or  cold  tea.  The  general  condition  of  the 
patient,  his  pulse  and  temperature,  must  be  constantly  under 
observation.  Wine,  brandy,  cognac,  champagne,  Tokay  wine  and 
strong  coffee  are  to  be  administered  to  the  aged  and  weak  as 
indicated. 

When  a  patient  is  in  a  condition  to  partake  of  food,  particular 
care  should  be  exercised  in  regard  to  the  kind  and  quantity  per- 
mitted.    At  first  only  liquid  foods,  such  as  bouillon  with  yolk  of 


TOXIC  GASTRITIS  455 

egg,  meat  juices  and  extracts,  albumin  water  and  leguminous 
soups,  should  be  allowed.  Should  obstinate  vomiting  interfere 
with  eating,  nutrient  enemata  may  be  given.  Great  caution 
should  be  exercised  when  the  patient  is  passing  from  liquid  to  solid 
food.  The  initial  solids  should  consist  of  sweetbread,  brain,  boiled 
fowl  (chicken,  squab),  minced  raw  meat,  minced  ham,  meat  jelly, 
Hour  and  milk  gruel,  tapioca,  mashed  potatoes,  milk,  crackers,  or 
zwieback.  The  return  to  a  full  diet  should  be  very  gradual,  not 
complete  until  ten  to  fourteen  days  after  the  cessation  of  all  the 
symptoms. 

Medicinal  Treatment. — The  same  drugs  prescribed  in  the  treat- 
ment of  milder  gastric  catarrh  are  indicated  in  the  infectious 
forms.  Since  in  these  severe  acute  cases  the  hydrochloric  acid 
secretion  is  diminished,  dilute  hydrochloric  acid  well  diluted  with 
water  should  be  given  three  times  a  day  (see  page  258).  This  will 
serve  the  additional  purpose  of  allaying  the  thirst.  Resorcinol 
may  be  given  for  nausea  and  foul-smelling  eructations.  To  reduce 
fever,  0.3  Gm.  (5  grains)  of  quinin  or  acetphenetidin  may  be  given; 
or  recourse  may  be  had  to  the  tepid  or  cold  bath.  Calomel,  0.015 
Gm.  (|  grain)  three  times  a  day,  will  often  exert  a  good  influence 
on  the  course  of  the  disease. 

When  the  infection  has  passed  to  the  intestine,  calomel  should 
be  given,  to  be  followed  if  necessary  by  resorcinol  with  salicylate 
of  bismuth;  the  following  formula  will  be  found  useful: 

Gm.  or  Cc. 

1$ — Bismuthi  salicylates 3 1 0  gr.  xlv 

Resorcinolis 2  0  gr.  xxx 

Glycerini 15 10  §ss 

Aquae 200 1 0  gvij 

Misce. 

Sig. — One  tablespoonful  every  three  hours. 

TOXIC  GASTRITIS. 

Etiology. — Severe  toxic  gastritis  may  be  caused  by  chemical  poi- 
sons, such  as  concentrated  mineral  acids,  caustic  alkalis,  ammo- 
nia, phenol,  oxalic  acid,  alcohol,  phosphorus,  arsenic,  potassium 
cyanid,  potassium  chlorate,  corrosive  sublimate',  lysol,  and  others. 

Pathology. — The  essential  feature  of  intoxication  by  the  heavy 
metals  and  phenol  is  that  at  an  early  stage  no  histologic  change  is 
seen,  even  though  the  tissue  be  dead.  It  is  "fixed"  just  as  is  tissue 
in  a  test-tube.  At  this  stage  there  is  no  reaction  in  this  part  of  the 
stomach  wall.  Later,  inflammatory  reaction  sets  in.  The  most 
marked  alterations  of  the  gastric  mucous  membrane  are  produced 
by  the  corrosive  poisons,  acids  and  alkalis,  oxalic  acid,  phenol,  lysol, 
and  corrosive  sublimate.  At  first  the  wall  of  the  lower  end  of  the 
greater  curvature  not  far  from  the  pylorus,  or  the  posterior  wall  of 
the  stomach,  is  attacked  by  these  poisons,  the  location  depending 


456  ACUTE  GASTRITIS 

on  the  position  of  the  patient  (that  is,  whether  lying  or  standing) 
when  the  poisonous  substance  is  ingested.  The  gastric  mucosa  is 
hyperemic  and  greatly  swollen,  subsequently  becoming  ulcerated; 
the  ulcers  sometimes  penetrate  to  the  serous  coat,  or  even  to  com- 
plete perforation.  In  recovery  the  patient  may  have  pronounced 
disturbance  of  the  motor  and  chemical  functions  of  the  stomach; 
there  is  apt  to  be  an  alteration  in  the  shape  and  size  of  the  organ, 
or  esophageal  stricture  due  to  cicatrization.  Alcohol  and  phos- 
phorus do  not  produce  such  marked  lesions,  but  cause  an  intense 
irritation  and  inflammation  of  the  mucosa  together  with  fatty 
degeneration  of  the  glandular  epithelium. 

Symptoms. — The  symptoms  will  vary  according  to  the  amount 
of  poison  taken.  There  is  always  intense  burning  pain  in  the 
pharynx,  along  the  esophagus,  and  especially  in  the  stomach. 
Vomiting  soon  commences,  but  does  not  bring  relief  to  the  patient. 
The  vomited  matter  contains  an  admixture  of  blood.  The  stom- 
ach is  usually  distended  and  the  abdomen  exceedingly  sensitive 
to  pressure.  Thirst  is  always  a  feature.  In  cases  of  great  sever- 
ity the  pulse  is  small,  the  lips  blue,  and  there  is  perspiration,  with 
slight  coma;  death  may  occur  in  collapse. 

Prognosis. — The  prognosis  in  such  cases  depends  upon  the  quan- 
tity of  poison  taken,  as  well  as  upon  the  condition  in  which  the 
patient  is  found.  Every  case  of  poisoning  should  be  considered 
serious,  and  recovery  a  matter  of  doubt. 

Treatment. — The  prime  requirement  is  to  remove  the  poison 
from  the  stomach  with  the  utmost  speed,  and  this  is  best  accom- 
plished by  lavage.  It  is  sometimes  dangerous  to  attempt  to 
introduce  the  tube,  owing  to  the  possibility  of  perforation.  Espe- 
cially is  this  likely  to  happen  in  poisoning  by  acids  or  caustic 
alkalis.  In  all  such  cases  the  best  mode  of  treatment  is  to  effect 
a  dilution  of  the  poison,  and  if  possible  its  neutralization. 

In  the  treatment  of  poisoning  by  inorganic  acids,  alkalis  are 
indicated  to  neutralize  any  free  acid  in  the  pharynx,  esophagus  or 
stomach.  Large  doses  of  magnesium  oxid,  200  Gm.  (§vij)  in 
four  parts  of  water;  sodium  carbonate  diluted  in  a  mucilaginous 
vehicle;  lime-water,  powdered  chalk,  and  large  quantities  of  sodium 
bicarbonate,  are  suitable  antidotes.  Care  should  be  exercised  in 
the  employment  of  chalk  and  bicarbonate  of  sodium,  owing  to 
the  generation  of  carbon  dioxid  on  contact  with  the  acid.  In 
poisoning  by  organic  acids,  saccharated  lime  may  be  given,  in 
addition  to  the  other  substances  mentioned,  for  the  purpose  of 
converting  the  acid  into  a  nearly  insoluble  lime  salt.  Cracked 
ice  should  be  administered,  and  ice  packs  applied  over  the  region 
of  the  stomach.     Morphin  may  be  given  for  the  relief  of  pain. 

In  cases  of  poisoning  by  alkalis,  such  acids  as  acetic  or  citric 
are  indicated  to  neutralize  the  caustic  effect  of  the  poison.  Lysol 
and  phenol  poisoning  call  for  thorough  lavage  with  large  quanti- 


PHLEGMONOUS  GASTRITIS  157 

ties  of  water  (2  or  3  liters);  large  doses  of  sodium  sulphate  are 
useful;  lime-water  and  saccharated  lime  produce  the  compara- 
tively harmless  phenolate  of  lime.  It  is  well  to  note,  too,  that 
grain  alcohol  is  the  nearest  approach  we  have  to  an  ideal  drug  for 
neutralizing  the  effect  of  phenol.  In  phosphorus  poisoning  the 
treatment  consists  of  long-continued  lavage  and  the  subsequent 
administration  of  half  a  teaspoonful  of  turpentine  every  half-hour 
(see  page  357). 

PHLEGMONOUS  GASTRITIS. 

This  is  among  the  rarest  of  gastric  diseases.  The  earliest 
description  of  the  disease  would  seem  to  be  in  a  communication 
by  Veranadeus  in  1620.  In  the  latter  half  of  the  seventeenth 
century  and  in  the  beginning  of  the  eighteenth  there  were  pub- 
lished observations  on  phlegmonous  gastritis  by  Borel  (1656), 
Sand  (1701),  Vorwaltner,  and  Bonet.  These  observations  describe 
the  circumscribed  form  only.  Andral  (1839)  and  Cruveilhier 
appear  to  have  been  the  first  to  observe  the  diffuse  form  of  puru- 
lent infiltration  of  the  gastric  walls.  In  their  case  a  fortunate 
accident  led  to  incisions  into  the  stomach  walls,  which  revealed  a 
diffuse  submucous  suppurative  inflammation.  Since  1860  many 
papers  on  both  the  circumscribed  and  the  diffuse  form  have  been 
published,  and  a  very  admirable  monograph  by  Leith,  of  Edin- 
burgh, in  1896.  Leith  was  able  to  collect  only  51  positive  cases 
of  the  diffuse  form  of  phlegmonous  gastritis  in  the  entire  literature 
of  the  subject,  and  the  total  number  of  cases  of  both  diffuse  and 
circumscribed  forms  is  given  as  85. 

The  disease  is  characterized  by  a  purulent  inflammation  of 
the  walls  of  the  stomach,  originating  in  the  submucous  coat  and 
gradually  extending  to  the  other  layers.  A  primary  and  a  secon- 
dary or  metastatic  form  of  the  disease  have  been  distinguished. 
The  condition  has  been  classified  also  as  "diffuse  phlegmonous 
gastritis,"  in  which  the  purulent  infiltration  of  the  stomach  extends 
over  a  large  area;  and  "circumscribed,"  or  so-called  abscess  of  the 
stomach.  It  usually  runs  an  acute,  though  occasionally  a  sub- 
acute, course.  Only  about  90  cases  have  been  reported,  of  which 
number  the  majority  were  males.  The  metastatic  form  of  the 
disease  usually  originates  in  infectious  diseases — puerperal  fever 
or  pyemia. 

Etiology. — The  cause  of  the  primary  affection  is  obscure.  Alco- 
holism has  been  suggested.  Traumatism,  dietetic  errors,  expo- 
sure, food  and  drug  poisoning,  puerperal  fever,  and  carcinoma  have 
been  noted  as  contributory  factors;  they  undoubtedly  lessen  the 
power  of  resistance  so  that  the  stomach  more  easily  becomes  a 
nidus  for  pyogenic  bacteria.  Kinnicutt  reports  a  case  of  phleg- 
monous gastritis  in  which  bacteriologic  examination  revealed  the 
universal  presence  of  the  streptococcus;  it  was  most  abundant 


458  ACUTE  GASTRITIS 

in  the  connective  tissue  of  the  submucosa  and  the  muscularis. 
Two  cases  were  reported  by  Robertson,  in  which  the  direct  cause 
was  a  virulent  streptococcus  in  the  gastric  submucosa,  entering 
through  a  defect  in  the  mucosa  or  carried  by  the  blood  or  lymph 
currents.  If  the  disease  be  due  to  bacterial  infection  of  the  sub- 
mucous coat  through  some  small  abrasion  of  the  mucosa — which 
is  the  most  plausible  explanation — then  it  is  strictly  analogous 
to  cellulitis  of  the  subcutaneous  tissues  due  to  a  cutaneous  defect 
healed  long  before  the  cellulitis  is  observed.  This  hypothesis 
gives  a  clue  to  the  surgical  treatment,  to  be  discussed  later. 

The  secondary  form  of  this  disease,  apparently  due  to  metastatic 
infection,  may  originate  from  carcinoma  or  ulcer  of  the  stomach. 
In  one  case  gastritis  phlegmonosa  has  been  observed  to  follow  an 
enterostomy. 

Pathology. — The  essential  lesion  is  a  widespread  inflammatory 
change  in  the  submucous  coat,  which  is  greatly  thickened,  usually 
of  a  yellowish-white  color,  and  so  much  softened  that  it  resembles 
pus.  Microscopically  the  appearance  is  that  of  fibrin  with  masses 
of  leukocytes  entangled  in  it.  This  change  is  nearly  always  more 
marked  in  the  pyloric  half  of  the  stomach,  a  fact  which  may  bear 
some  relation  to  the  anatomic  situation  of  the  oxyntic  or  acid- 
producing  cells,  of  the  gastric  mucosa.  The  muscular  coat  shows 
varying  degrees  of  infection  and  degeneration  of  the  muscular 
elements.  The  serous  coat  is  sometimes  unaffected,  but  it  may 
show  leukocytic  infiltration,  especially  in  cases  where  a  secondary 
purulent  peritonitis  is  present.  The  mucosa  is  in  many  instances 
normal,  but  in  others  it  is  acutely  inflamed — raised  from  its  bed  in 
ridges;  in  others  again  the  deeper  layers  of  glandular  tubules  are 
atrophied;  while  in  a  few  of  the  recorded  cases  the  mucous  sur- 
faces have  been  pitted  with  tiny  apertures,  giving  it  the  appear- 
ance of  a  sieve,  through  the  meshes  of  which  pus  could  be  squeezed 
from  the  infiltrated  submucous  layer.  The  duodenum  is  very 
rarely  altered,  and  then  only  the  mucosa  is  inflamed.  Of  secondary 
lesions,  peritonitis,  seropurulent  or  purulent,  is  the  commonest, 
and  it  has  been  found  in  rather  more  than  half  the  cases.  Peri- 
carditis, pleurisy,  and  abscess  of  the  liver  have  also  been  observed. 

Symptoms  and  Course. — The  course  of  the  diffuse  form  of  this 
disease  is  atypical.  We  may  have  a  severe  acute  gastritis,  with 
high  fever,  sometimes  as  high  as  104°  F.,  violent  pains  and  uncon- 
trollable vomiting,  the  abdomen  greatly  distended,  the  pulse 
feeble;  symptoms  of  collapse  follow  and  the  termination  is  usually 
fatal. 

The  course  of  the  circumscribed  form  is  similar,  except  that  it 
is  of  longer  duration,  extending  sometimes  over  several  weeks. 
Sometimes  a  tumor  can  be  felt  in  the  region  of  the  stomach. 

The  prognosis  in  both  forms  of  phlegmonous  gastritis  is  very 
grave,  practically  hopeless.    Up  to  1896,  Leith,  who  had  pub- 


PHLEGMONOUS  GASTRITIS  I.V.i 

lished  the  best  account  of  the  disease,  found  no  authentic  cases 
of  recovery;  and  from  the  records  of  cases  since  that  date  it  appears 
probable  that  the  few  recoveries  noted  were  really  not  cases  of 
primary  phlegmonous  gastritis,  but  abscess  of  the  stomach. 

Treatment.  Since  the  diagnosis  is  never  positive,  the  treatment 
must  be  more  or  less  symptomatic.  There  is  no  successful  internal 
treatment  of  this  disease.  The  stomach  should  be  spared  as  much 
as  possible.  Food  and  drink  should  be  administered  per  rectum. 
Ice-bags,  and  cocain,  morphin  or  eodein  hypodermically,  are  indi- 
cated for  the  relief  of  pain.  High  temperatures  are  to  be  con- 
trolled by  the  use  of  antipyretic  drugs.  Stimulants  should  be 
administered  early  in  the  disease,  as  well  as  when  symptoms  of 
collapse  appear.  If  the  nature  of  the  infecting  organism  can  be 
learned,  the  appropriate  bacterial  vaccine  should  be  administered. 

This  disease  is  essentially  surgical.  Gastrostomy  or  gastro- 
enterostomy is  suggested  as  an  appropriate  method  of  dealing  with 
the  lesion  surgically,  but  it  is  difficult  to  see  how  a  surgical  opera- 
tion is  going  to  cure  a  cellulitis  of  the  stomach  wall.  Proba.bly 
incisions  down  to  the  submucous  coat,  with  free  exposure  of  the 
stomach  wall,  and  packing-off  of  the  peritoneal  cavity  with  gauze 
left  in  position  for  several  days,  would  offer  the  best  chance  of 
recovery.  This  is  the  treatment  of  cellulitis  in  subcutaneous 
lesions,  and  if  it  could  be  effected  without  infecting  the  general 
peritoneal  cavity  it  seems  reasonable  to  hope  that  satisfactory 
results  might  be  obtained. 


CHAPTER  XXIII. 

CHRONIC  GASTRITIS— ACID  GASTRITIS— SUBACID 

GASTRITIS— AN  ACID  GASTRITIS;  ACHYLIA 

GASTRICA. 

CHRONIC  GASTRITIS. 

Chronic  catarrhal  gastritis  is  a  chronic  inflammation  of  the 
gastric  mucous  membrane,  of  varying  degrees  of  intensity,  pre- 
senting symptoms  more  or  less  characteristic  of  widely  different 
forms  of  gastric  derangement.  It  is  a  disease  which  requires  for 
its  positive  diagnosis  and,  as  a  rule,  for  even  probable  diagnosis, 
an  examination  of  the  gastric  secretion. 

Etiology. — When  the  irritating  cause  of  acute  gastritis  persists, 
chronic  gastritis  is  the  natural  consequence;  but  there  are  generally 
other,  often  altogether  different,  etiologic  factors.  Gastritis  occurs 
as  a  concomitant  manifestation  in  many  grave  affections  of  the 
stomach,  and  we  find  it  almost  always  in  carcinoma  leading  to 
atrophy  of  the  mucous  membrane.  In  all  conditions  which  induce 
stagnation  in  the  area  of  the  portal  vein,  notably  cardiac  and 
pulmonary  affections,  chronic  gastritis  supervenes  as  a  result  of 
the  engorgement.  It  also  occurs  in  conditions  which  disturb  the 
composition  of  the  blood,  such  as  chronic  intoxications,  chlorosis, 
anemia,  chronic  renal  affections,  gout,  diabetes,  and  infectious 
diseases.  After  grave  acute  infections,  inflammatory  changes  of 
the  gastric  mucosa  are  easily  demonstrable. 

Extreme  temperatures,  both  hot  and  cold,  attacking  the  gastric 
mucosa,  may  in  the  course  of  time  cause  permanent  degenerative 
changes.  Overloading  of  the  stomach,  food  that  is  hard  to  digest, 
insufficient  mastication  and  defective  teeth  are  very  important 
factors.  Neglect  in  the  care  of  the  mouth,  especially  when  arti- 
ficial teeth  are  worn,  may  lead  to  gastric  catarrh.  It  often  hap- 
pens that  gastric  symptoms  occur  in  perfectly  healthy  individuals 
shortly  after  they  commence  to  use  artificial  teeth  which  they  do 
not  keep  clean.  Oral  sepsis  is  the  cause  of  many  cases  of  chronic 
gastritis.  Affections  of  the  nose,  the  nasopharynx,  the  accessory 
sinuses,  or  any  ulceration,  may  lead  to  gastritis  if  the  pathologic 
secretions  are  swallowed  (see  page  290). 

In  the  etiology  far  too  little  attention  is  given  to  the  use,  or 
rather  abuse,  of  articles  of  diet,  except  perhaps  alcohol,  which 
has  long  been  considered  one  of  the  causes  of  chronic  gastritis. 
Increased  importance  is  now  also  given  to  tobacco  as  a  causative 


CHRONIC  GASTRITIS  401 

factor.  Such  medicaments  as  balsam  copaiba,  menthol  and  santal 
oil  may  occasionally  cause  chronic  gastritis. 

Pathology. — In  chronic  gastritis  it  is  not  the  superficial  epithe- 
lium alone  that  is  affected,  but  the  inflammatory  process  extends 

to  the  glandular  epithelium  and  to  the  interstitial  tissue.  In  the 
initial  stage  of  simple  chronic  gastritis  the  mucous  membrane  is 
pale  gray  in  color  and  covered  with  closely  adherent  tenacious 
mucus.  The  veins  are  enlarged,  and  patches  of  ecchymosis  are 
sometimes  seen.  The  glands  are  subject  to  parenchymatous  and 
interstitial  inflammation,  presenting  a  microscopic  picture  of 
erosion,  cloudy  swelling,  or  atrophy,  depending  upon  the  stage  of 
the  disease.  It  is  not  possible  to  differentiate  between  the  peptic 
and  the  parietal  cells,  owing  to  the  fact  that  the  tubes  have  lost 
their  regular  form  and  instead  we  have,  as  Ewald  expresses  it, 
"atypical  branching  like  the  fingers  of  a  glove."  There  is  an 
infiltration  of  round  cells  and  proliferation  of  connective  tissue, 
which  exert  pressure  on  the  glands,  thus  inhibiting  their  normal 
functions.  As  these  pathologic  changes  become  more  marked  the 
secretion  becomes  progressively  less  until  the  atrophic  stage  is 
reached  and  secretion  ceases  entirely.  Meanwhile  a  mucoid  degen- 
eration of  the  cells  lining  the  tubules  takes  place  and  may  even 
extend  to  the  fundus  of  the  glands.  There  is  a  proliferation  of 
connective  tissue,  so  that,  toward  the  pylorus  in  particular,  the 
stomach  wall  has  a  rough,  wrinkled,  mammillated  appearance, 
the  etat  mamehnne  of  the  French,  a  condition  which  is  sometimes 
so  prominent  that  it  has  been  described  as  gastritis  polyposa.  The 
pathologic  changes  may  even  lead  to  stenosis  of  the  pylorus.  One 
of  the  important  features  of  the  fibrosis  which  develops  between  the 
different  layers  of  the  stomach  wall  (especially  in  the  submucosa) 
is  that  it  interferes  with  motility  or  elasticity  of  the  mucosa  upon 
the  muscularis.  It  is  therefore  more  or  less  essentially  associated 
with  variation  of  motility. 

The  inflammation  in  the  more  aggravated  cases  may  pass  to  the 
muscular  layers,  causing  partial  destruction,  to  be  replaced  by 
connective-tissue  fibers.  Belonging  to  this  form  of  the  disease  is 
sclerotic  gastritis  (cirrhosis  ventriculi),  in  which  the  walls  of  the 
stomach  undergo  a  connective-tissue  metamorphosis,  sometimes  to 
such  an  extent  that  the  stomach  is  greatly  reduced  in  size.  The 
fact  is  now  recognized  that  there  may  be  such  destruction  of  the 
glandular  elements  by  a  progressive  growth  of  interstitial  tissue 
that  ultimately  scarcely  a  trace  of  secreting  tissue  remains. 

Symptoms. — The  local  symptoms  have  a  strong  resemblance  to 
those  of  other  forms  of  gastric  disturbance.  The  disease,  as  a 
rule,  develops  very  slowly,  and,  as  in  the  case  of  most  chronic 
diseases,  changes  from  time  to  time.  The  appetite  varies;  some- 
times it  is  very  poor,  and  sometimes  it  is  good.  Patients  usually 
complain  of  a  disagreeable  taste,  which  they  describe  as  salty  or 


462         CHRONIC  GASTRITIS  AND  ACHYLIA  G  AST  RICA 

pappy,  or  at  times  sour;  of  thirst,  salivation,  and  eructation  of 
gas  or  food  remnants,  which  may  be  sour,  rancid,  or  tasteless. 
The  breath  is  often  fetid.  Nausea  is  rather  common.  Pressure 
and  fulness  are  experienced  after  eating.  Patients  complain  of 
palpitation  of  the  heart.  Belching  (which  is  very  annoying  to 
the  patient)  relieves  both  the  pressure  and  the  consequent  palpi- 
tation. Irregular  stools,  constipation  and  diarrhea  are  commonly 
met  with  in  chronic  catarrhal  gastritis.  Patients  suffer  from  head- 
aches, vertigo,  and  disturbed  sleep.  There  are  vasomotor  dis- 
turbances, with  sensations  of  coldness  of  the  extremities. 

Objective  Symptoms. — The  patients,  as  a  rule,  appear  to  be  well 
nourished;  but  some  are  seen  to  have  lost  weight  and  look  ema- 
ciated. The  tongue  is  usually  coated  gray  or  yellowish-gray; 
still,  in  many  cases  of  well-marked  chronic  gastritis  the  tongue  is 
clean.  There  may  be  no  offensive  odor  in  the  mouth,  or  if  there 
is  any  it  may  be  due  to  carious  teeth  or  some  pathologic  condition 
of  the  nose  or  throat.  The  gastric  region  often  appears  bloated. 
Palpation  reveals  slight  sensitiveness  of  the  entire  area  over  the 
stomach.  The  pylorus  may  be  palpated  when  thickened  by 
muscular  hypertrophy. 

Diagnosis. — It  is  seen  that  there  are  no  symptoms,  either  sub- 
jective or  objective,  which  are  pathognomonic  of  the  disease.  An 
approximate  diagnosis  can  be  established  only  by  an  examination 
of  the  secretory  and  motor  functions  of  the  stomach  and  the  anam- 
nesis. The  presence  of  mucus  in  the  stomach  must  be  ascertained 
before  we  are  justified  in  making  a  diagnosis  of  chronic  gastric 
catarrh.  From  the  stomach  under  normal  conditions  it  is  possible 
to  obtain  only  a  few  isolated  flakes  of  mucus,  even  after  most 
thorough  lavage.  In  chronic  gastritis  mucus  is  usually  present 
in  marked  quantities,  and  is  found  mixed  with  food  remnants. 
Mucus  which  enters  the  stomach  from  the  nose,  pharynx  or  trachea 
is  found  upon  the  surface  of  the  liquid  or  food  removed  from  the 
stomach  with  the  stomach  tube.  In  chronic  gastritis  the  picture  of 
mucus  entangling  large  numbers  of  cells  is  characteristic,  but  free 
polynuclears  are  of  greater  significance. 

The  acid  secretion  in  chronic  gastric  catarrh  varies.  In  the 
initial  stages  the  percentage  of  free  hydrochloric  acid  is  often 
found  to  be  normal.  Sometimes  there  is  hyperacidity,  a  condition 
which  corresponds  to  the  acid  gastritis  described  by  Boas.  It  is  a 
gastritis  with,  increased  production  of  mucus  and  an  abnormally 
active  secretion  of  hydrochloric  acid.  The  mucus  siphoned  out 
early  in  the  morning  after  the  night's  fast  may  give  a  positive 
hydrochloric  acid  reaction.  Acid  gastritis  is  an  early  form  of 
chronic  gastritis,  and  is  found  very  frequently  in  alcoholic  patients. 
As  the  disease  progresses,  the  secretory  function  becomes  impaired, 
with  a  resultant  decline  from  the  normal  amount  of  free  hydro- 
chloric acid.     In  the  more  protracted  cases  there  is  no  free  hydro- 


CHRONIC  GASTRITIS  163 

chloric  acid  at  all,  and  the  other  constituents  of  the  gastric  secre- 
tion arc  very  much  diminished  in  quantity.  The  diminution  of 
free  hydrochloric  acid  is  in  direct  proportion  to  the  intensity  of 
the  disease  process;  when  very  marked,  the  condition  is  designated 
subacid  gastritis.  Further  progress  of  the  disease  converts  the 
subacidity  into  anacidity,  a  condition  in  which  the  formation  of 
pepsin  begins  to  fail.  This  pathologic  state  is  known  as  anacid 
gastritis. 

The  final  stage  of  the  disease  is  that  of  chronic  anacid  gastritis 
with  atrophy  of  the  secreting  glands.  The  pathologic  changes  in 
the  gastric  mucosa  are  so  great  as  to  preclude  the  possibility  of 
restitution  of  the  secretory  functions  of  the  stomach.  When  this 
stage  is  reached,  rennin  as  well  as  pepsin  and  hydrochloric  acid 
arc  absent.  The  term  "subacidity"  is  applied  to  cases  in  which 
free  hydrochloric  acid  is  decreased  and  the  total  acidity  is  less  than 
40  degrees;  the  secretion  of  the  ferments  may  be  normal  (see 
page  95). 

It  is  a  question  whether  gastric  anacidity  may  exist  as  an  inde- 
pendent primary  affection  (achylia  gastrica),  or  whether  it  is  to  be 
always  regarded  as  a  later  stage  of  chronic  gastritis  characterized 
by  atrophy  of  the  gastric  mucosa.  The  possibility  of  gastric 
anacidity  as  a  primary  affection  would  seem  to  be  assured  by 
cases  of  purely  nervous  or  functional  disturbance,  or  by  cases  in 
which  there  is  an  inherent  deficiency  in  the  secretory  function  of 
the  stomach.  The  examination  of  stomach  contents  in  such  cases 
reveals  an  unaltered  condition  of  the  test  meal.  The.  particles  of 
bread  are  larger  or  smaller,  depending  upon  the  thoroughness  of 
mastication,  and  have  the  appearance  of  being  merely  moistened 
or  softened  by  the  water.  Mucus  is  not  present.  The  total  acid- 
ity is  extremely  low — 4  to  6  degrees,  and  frequently  zero.  The 
reaction  of  the  stomach  contents  is  very  slightly  acid,  sometimes 
amphoteric  on  account  of  the  presence  of  phosphates  in  the  food. 

Very  often  individuals  with  anacidity  or  subacidity  feel  perfectly 
well,  or  at  least  experience  no  great  discomfort.  They  appear  well 
nourished.  Cases  ha've  been  observed  in  which  gastric  anacidity 
had  persisted  for  periods  of  twelve  to  fifteen  years.  In  this  class 
of  cases  the  power  of  the  stomach  to  digest  protein  is  entirely 
absent,  so  that  the  small  intestine  receives  all  the  protein  in  an 
unchanged  condition.  The  test-diet  stool  is  characteristic  under 
such  conditions  (see  Chapter  IV). 

The  motor  activity  of  the  stomach  is  usually  normal.  Stagna- 
tion is  found  only  in  those  cases  in  which  there  is  hypertrophy  of 
the  muscular  layers  of  the  pylorus. 

Prognosis. — The  prognosis  of  chronic  gastritis  is  favorable;  the 
disease  responds  to  treatment,  so  that  a  complete  cure  or  material 
improvement  may  be  anticipated.  Relapses  are,  however,  likely 
to  occur. 


464        CHRONIC  GASTRITIS  AND  ACHY  LI  A  GASTRICA 


ACHYLIA  GASTRICA. 

"Achylia  gastrica"  is  a  term  introduced  into  medical  literature 
by  Einhorn  to  denote  absence  of  gastric  secretion.  The  stomach 
contents  contain  no  free  or  combined  hydrochloric  acid;  the  fer- 
ments are  likewise  absent  or  greatly  reduced  in  amount.  Achylia 
is  a  sign  of  disturbed  function  of  the  stomach  which  may  accom- 
pany such  diseases  as  carcinoma,  severe  anemia,  or  chronic  gastric 
catarrh.  It  may  also  occur  as  a  purely  functional  disturbance 
wholly  apart  from  primary  organic  disease  of  the  stomach  or  other 
organs. 

In  achylia  gastrica  there  is  no  chymification  of  the  gastric  con- 
tents; the  aspirated  parts  of  a  test  breakfast  have  the  appearance 
of  crumbs  of  bread  in  water  (see  Chapter  II).  The  contents  of 
the  stomach  are  expelled  with  abnormal  rapidity.  A  test  breakfast 
may  be  emptied  into  the  duodenum  in  a  quarter  to  half  the  nor- 
mal time  (hypermotility) .  There  being  no  hydrochloric  acid,  the 
pylorus  does  not  close  as  it  would  under  normal  conditions  (see 
page  94). 

Achylia  gastrica  senilis  is  a  true  wasting  disease  and  is  found 
to  consist  of  a  senile  atrophy  of.  the  gastric  mucosa.  Achylia  fol- 
lowing chronic  atrophic  gastritis  occurs  between  the  ages  of  thirty 
and  fifty.  In  these  cases,  as  distinguished  from  the  cases  of  primary 
achylia,  there  is  more  or  less  mucus  mixed  with  the  stomach  contents. 

Achlorhydria  hemorrhagica  gastrica  is  a  condition  of  achylia  due 
to  reflex  inhibition,  characterized  pathologically  by  superficial 
ulceration  of  the  mucosa,  hyperemia  and  extravasation  of  blood. 
Etiologically  it  is  often  secondary  to  chronic  appendicitis,  chole- 
cystitis, or  pancreatitis  (see  page  427).  In  a  majority  of  cases 
diplococci  and  streptococci  are  found  in  the  gastric  mucosa.  Their 
presence  leads  us  to  believe  that  the  condition  may  be  of  focal 
origin  (see  page  290).  The  diagnosis  is  made  by  the  finding  of 
an  achlorhydria  and  the  demonstration  of  the  presence  of  occult 
blood  (see  page  86) .  The  treatment  is  the  same  as  that  of  chronic 
gastritis,  with  removal  of  the  original  cause  by  surgical  intervention. 

Carcinoma  of  the  stomach  is  preceded  or  attended  by  achylia. 
When  achylia  occurs  after  the  age  of  forty,  the  possibility  of  car- 
cinoma should  be  borne  in  mind.  Every  case  of  carcinoma  of  the 
fundus  at  some  period  of  its  existence  shows  no  other  signs,  sub- 
jective or  objective,  than  those  of  chronic  gastritis  and  achylia 
gastrica. 

In  cases  of  chronic  cholelithiasis,  and  particularly  pancreatic 
affections,  the  possibility  of  achylia  gastrica  being  the  cause  should 
not  be  overlooked;  nor  should  we  forget  the  frequent  etiologic 
role  of  this  gastric  condition  in  intermittent  intestinal  catarrhs 
(colitis,  gastrogenic  diarrhea)  continuing  for  days  or  weeks  and 
alternating  with  normal   evacuation  or  with  constipation. 


ACHY  LI  A  GASTRIC  A  465 

Etiology.— The  etiology  of  achylia  gastrica  is  still  unexplained. 

From  clinical  observation  it  would  seem  that  the  internal  secretions 
are  in  some  way  involved.  Then,  again,  the  quick  return  to  normal 
gastric  secretion  after  an  appendectomy  for  chronic  appendicitis 
associated  with  achylia  gastrica  would  suggest  an  impingement 
on  the  nerve  terminals,  with  reflex  inhibition  of  gastric  secretion. 
Often  patients  do  not  consult  a  physician  until  the  onset  of  a 
secondary  diarrhea  or  pancreatic  insufficiency.  They  may  give  a 
personal-  history  of  no  previous  symptoms.  Even  the  diarrhea 
(see  Chapter  XXXVIII)  may  have  existed  for  years  without 
causing  any  special  complaint,  being  a  deuteropathic  manifesta- 
tion of  increased  decomposition  and  deficient  chymification  of  the 
ingested  food. 

Achylia  gastrica  is  always  present  in  pernicious  anemia,  both 
conditions  being  probably  due  to  total  atrophy  of  the  gastro- 
intestinal mucosa,  which  permits  the  blood  to  form  hemolysins 
that  result  in  blood  degeneration. 

Congenital  achylia  gastrica  is  caused  by  a  defective  primary 
development  of  the  gastric  mucosa,  while  atrophy  is  always  the 
result  of  inflammation.  Achylia  gastrica  often  occurs  at  as  early 
a  period  as  childhood,  when  a  preceding  chronic  gastritis  can  be 
excluded  and  gastric  symptoms  have  never  manifested  them- 
selves. These  children  are  taken  to  the  physician  on  account  of 
defective  physical  development,  debility,  anemia,  anorexia,  and 
occasional  diarrhea.  Adults  with  periodically  intermittent  diar- 
rhea have  often  suffered  since  childhood.  They  remain  emaciated 
for  life,  despite  all  kinds  of  treatment,  even  hyperalimentation. 
After  a  period  of  well-being  their  metabolism  is  disturbed  by  slight 
dietary  errors,  overexertion,  or  excitement,  leading  to  diarrhea 
with  its  debilitating  sequelae. 

This  condition  is  often  found  as  a  family  affection,  most  of 
the  sufferers  having  a  pronounced  neurasthenic  appearance.  They 
differ,  however,  from  ordinary  neurasthenic  patients  by  the  anacid 
condition  of  their  stomach  contents  and  by  other  symptoms  of 
achylia  gastrica.  A  marked  feature  in  neurotic  patients  is  the 
fact  that  achylia  suddenly  occurs  and-  then  again  disappears  (het- 
erochylia);  this  is  explained  by  the  supposition  of  a  temporarily 
exhausted  function  of  the  gastric  mucosa.  From  this  considera- 
tion it  follows  that  not  every  case  of  achylia  gastrica  implies  an 
advanced,  incurable  affection  of  the  glands.  Derangement  of  the 
vegetative  nervous  system  may  be  the  cause  of  the  achylia  (see 
page  387). 

Pathology. — The  mucous  membrane  has  been  for  the  most  part 
normal  in  many  cases  examined,  while  in  some  cases  the  gastric 
glands  were  found  to  be  atrophied. 

Symptoms. — The  clinical  symptoms  of  achylia  gastrica  resemble 
those  of  chronic  gastritis:  loss  of  appetite,  nausea,  vomiting,  slight 
30 


466         CHRONIC  GASTRITIS  AND  ACHYLIA  GASTRICA 

pains,  and  eructations.  In  many  instances  the  patient  feels  well, 
and  the  existence  of  the  disease  is  discovered  by  accident. 

Achylia  gastrica  may  be  unmarked  by  the  presence  of  any 
distressing  symptoms,  or,  if  such  symptoms  are  present,  they 
may  be  wholly  non-characteristic  of  the  pathologic  condition. 
The  symptoms  usually  consist  of  diminished  desire  for  food,  pres- 
sure, fulness  in  the  stomach,  discomfort  after  eating,  or  eructations. 
There  is  often  an  acceleration  of  the  motility  of  the  stomach, 
said  to  be  due  to  the  absence  of  hydrochloric  acid;  hydrochloric 
acid,  if  present,  would  cause  a  periodic  closure  of  the  pylorus. 
The  food  passes  with  more  than  normal  rapidity  into  the  small 
intestine.  Patients  with  achylia  gastrica  may  maintain  a  fair 
state  of  health  so  long  as  the  small  intestine  is  functionally  active. 
Should  intestinal  digestion,  however,  become  impaired,  the  result 
would  be  a  diarrhea  (gastrogenic),  causing  marked  emaciation  or 
even  endangering  life.     (See  Chapter  XXXVIII.) 

Cases  described  as  secondary  achylia  are  sometimes  found 
accompanying  such  diseases  as  diabetes,  tuberculosis,  cirrhosis  of 
the  liver,  cardiac  disease,  and  arteriosclerosis  of  the  abdominal 
vessels.  Then  there  is  that  form  of  achylia  which  accompanies 
grave  cases  of  anemia,  pernicious  anemia,  and  the  anemia  due  to 
the  Bothriocephalus  latus.  The  relation  between  achylia  and  these 
pathologic  conditions  is  not  clear.  The  test-diet  stool  findings  are 
important  (see  page  131). 

TREATMENT  OF  CHRONIC  GASTRITIS  AND  ACHYLIA 
GASTRICA. 

Chronic  gastritis  and  achylia  gastrica  have  as  a  common  mani- 
festation a  perversion  of  gastric  secretion  which  consists  for  the 
most  part  of  a  diminution  in  activity  of  the  secretory  function. 
This  common  functional  derangement  renders  it  advantageous  to 
discuss  the  treatment  of  the  two  conditions  together. 

Since  repeated  attacks  of  simple  acute  gastritis  may  result  in 
the  development  of  chronic  gastritis,  it  is  important  that  the 
patient  avoid  any  excesses  "or  practices  which  predispose  to  the 
attacks.  The  food,  neither  too  hot  nor  extremely  cold,  and  not 
highly  spiced,  should  be  masticated  thoroughly,  and  the  patient 
should  avoid  overindulgence  in  alcohol  and  tobacco.  The  mouth 
and  teeth  must  be  kept  in  good  condition.  Slow  eating  followed 
by  rest,  exercise  in  the  open  air,  sleeping  with  the  windows  open, 
and  cold  salt-water  sponging  at  night  followed  by  a  brisk  rub,  are 
excellent  by  way  of  prophylaxis. 

Diet. — The  regulation  of  diet  is  perhaps  the  most  important 
factor  in  the  treatment  of  conditions  marked  by  subacidity  or 
anacidity,  since  a  restoration  of  the  secretory  functions  of  the 
stomach  to  normal  is  sometimes  impossible. 


DIETETIC  TREATMENT  4G7 

The  power  to  digest  protein  is  either  greatly  impaired  or  alto- 
gether absent.  The  digestion  of  carbohydrates  in  the  stomach 
would  be  satisfactory  were  it  not  for  the  cellulose  enveloping 
the  starch  granule;  but  proteolysis  must  be  carried  on  for  the  most 
part  or  altogether  by  the  small  intestine.  The  unusual  demand 
made  upon  the  small  intestine  will  sooner  or  later  result  in  impair- 
ment of  its  function.  It  is  seen,  then,  that  rational  treatment 
must  be  directed  toward  protecting  the  stomach  and  small  intes- 
tine. A  diet  rich  in  carbohydrate,  with  a  minimum  of  protein, 
is  indicated.  The  individual  tastes  of  patients  should  not,  how- 
ever, be  ignored.  Some  patients  object  to  a  monotonous  diet. 
To  avoid  aversion  certain  concessions  may  be  granted,  but  all 
food  should  be  tender  and  susceptible  of  thorough  mastication. 
In  chronic  gastritis  spiced  foods  may  be  permitted,  owing  to  their 
stimulating  influence  upon  the  appetite.  A  reduction  of  the 
chlorin  supply  to  the  body  induces  a  decrease  in  the  quantity  and 
acidity  of  the  gastric  juice.  The  giving  of  sodium  chlorid  with 
food  under  such  conditions  assists  in  remedying  the  decrease  of 
hydrochloric  acid  in  the  gastric  juice.  In  spite  of  apparent  restric- 
tion, the  choice  of  appropriate  articles  of  diet  may  be  sufficiently 
varied.  The  patient  may  be  allowed  all  the  tender  meats,  such 
as  fowl,  brain,  or  lean  fish.  Meat  should  be  thoroughly  roasted 
or  boiled ;  but  raw,  pickled,  or  smoked  meats  and  salted  fish  should 
be  avoided.  The  daily  quantity  of  meat  should  not  exceed  150 
grams  (5  ounces),  and  in  severe  cases  not  more  than  100  grams 
(3  ounces)  should  be  taken  during  the  day.  Meat  may  be  replaced 
by  eggs,  soft-boiled  or  in  the  form  of  egg  soups  or  light  omelets. 
Milk  is,  as  a  rule,  well  borne,  and  is  strongly  recommended;  it 
may  be  employed  as  a  vehicle  for  somatose  or  plasmon,  and  its 
digestibility  may  be  further  increased  by  the  addition  of  pegnin. 
Fats  in  the  form  of  butter  and  cream  are  permitted  this  class  of 
patients.  Vegetables  may  be  prescribed  in  the  form  of  thick 
strained  soups  (rice,  tapioca,  sago,  peas,  lentils);  and  mashed 
potatoes  in  moderate  quantities  are  permissible.  Biscuits,  zwie- 
back, toast,  stale  white  bread,  which  can  be  broken  up  fine  in 
the  mouth  or  softened  by  being  dipped  into  fluids,  are  indicated. 
Such  condiments  as  salt,  pepper  and  mustard  have  a  stimulating 
effect,  though  they  will  not  bring  back  the  gastric  secretion.  The 
meat  extracts  have  a  similar  action.  Pure  water  or  weak  lemon- 
ade is  the  most  satisfactory  beverage  for  allaying  the  thirst,  and 
is  best  taken  during  the  intervals  between  meals.  "Carbonated 
waters  are  also  good. 

Gastric  motility  is  usually  normal  in  chronic  gastritis.  When, 
however,  there  is  any  disturbance  in  motility,  it  may  be  overcome 
by  making  the  meals  small  and  frequent,  thus  avoiding  the  over- 
distention  of  the  stomach  which  large  meals  are  apt  to  induce. 
The  quantity  of  liquids  should  be  restricted,  inasmuch  as  they 
tend  to  produce  hyperdistention. 


468        CHRONIC  GASTRITIS  AND  ACHYLIA   GASTRICA 

Ewald's  diet  for  chronic  gastritis  is  as  follows: 

8  a.m.     150  to  200  Gm.  tea  [1  cup],  with  75  to  100  Gm.  [3  ozs.]  stale  white 
bread,  toast  or  zwieback. 
10  a.m.     50  Gm.  [2  ozs.]  white  bread,  10  Gm.  butter,  50  Gm.  [2  ozs.]  cold 

meat  or  ham,  one-third  liter  [1  glass]  of  milk. 
2  p.m.      150  to  200  Gm.  [1  cup]  water,  milk,  or  bouillon  of  the  white  meats, 
100  to  125  Gm.  [3  to  4  ozs.]  meat  or  fish,  80  to  100  Gm.  [about 
3  ozs.]  vegetables,  80  Gm.  stewed  fruit  [one  "helping"]. 
4  to  5  p.m.     One-fourth  to  one-third  liter  [1  glass]  of  warm  milk  (occasionally 

mixed  with  cocoa  or  coffee). 
7  to  8  p.m.     200  Gm.  [1  cup]  soup  or  pap,  50  Gm.  [2  ozs.]  white  bread,  10  Gm. 

butter. 
Occasionally  at  10  p.m.     50  Gm.  [2  ozs.]  white  bread  (biscuits  or  zwieback),  one 
cup  of  tea. 

The  distribution  of  meals  should  conform  as  nearly  as  possible 
to  the  custom  of  the  community  in  which  the  patient  lives.  In 
order  to  permit  the  patient  to  have  a  greater  variety  of  food,  it  is 
best  not  to  point  out  a  few  articles  he  should  eat,  but  to  mention 
only  those  he  should  avoid.  Forbid  meat  with  very  tough  fibers, 
meat  from  too  old  animals,  too  fresh  meat  (right  after  slaughtering), 
and  meat  that  contains  too  much  fat  (like  pork);  forbid  sausages, 
lobster,  salmon,  chicken  salad,  mayonnaise,  cucumbers,  pickles, 
cabbage,  and  strong  alcoholic  drinks. 

The  gastric  secretion  persists  to  a  slight  degree  in  chronic  atro- 
phic gastritis  and  in  the  severe  forms  of  chronic  gastritis  where  the 
mucous  membrane  has  undergone  structural  or  atrophic  change, 
though  the  quantity  of  hydrochloric  acid  secreted  may  be  very 
small.  Patients  may  be  allowed  meat,  very  finely  divided.  An 
effort  should  be  made  to  increase  the  secretory  powers  of  the 
stomach  by  prescribing  a  dietary  adapted  to  this  purpose.  Meat 
extractives,  condiments,  bouillon  and  extract  of  beef  are  recom- 
mended. The  mode  of  preparation  and  of  serving  the  food,  if 
attractive,  will  have  a  stimulating  action  on  the  gastric  functions. 
The  supply  of  beverages  should  be  limited,  especially  during  the 
meal,  in  order  to  avoid  a  further  dilution  of  the  gastric  ferments 
which  are  present  only  in  small  quantities. 

Diet  List  (Boas). 

Calories. 

7  a.m.     200  Gm.  milk  with  40  Gm.  cocoa  and  30  Gm.  sugar    .      .     462.0 

50  Gm.  biscuits  or  zwieback 187.0 

10  a.m.       50  Gm.  white  bread,  30  Gm.  butter 343.0 

One  egg  or  50  Gm.  minced  ham 100.0 

1  p.m.     Soup  (30  Gm.  tapioca,  10  Gm.  butter) 352 . 6 

One  egg,  100  Gm.  noodles  or  spinach,  100  Gm.  bean  puree, 

100  Gm.  carrots,  50  Gm.  mashed  potatoes    ....  282.0 
100  Gm.  breast- of  young  chicken,  veal  cutlet,  or  veal 

(steamed),  or  100  Gm.  squab,  game  or  fish    ....  106.4 

100  Gm.  rice  omelet,  or  omelet  with  ham 288.0 

4  p.m.      100  Gm.  milk  with  tea,  20  Gm.  sugar 147.5 

25  Gm.  biscuits 93 . 5 

8  p.m.       50  Gm.  white  bread,  30  Gm.  butter 343.0 

50  Gm.  minced  meat 59.5 

Total  calories 2764.5 


MEDICINAL  THEM  VEST  469 

Medicinal  Treatment.  Hydrochloric  Acid. — In  the  treatmenl  of 
chronic  gastritis,  medicaments  occupy  a  secondary  place  com- 
pared with  diet  and  hygiene.  Of  the  drug  agents,  hydrochloric 
acid  is  most  important  and  most  frequently  employed,  the  object 
of  its  use  being  to  supplement  the  deficiency  of  the  gastric  juice 
(see  page  258).  In  all  cases  characterized  by  a  diminution  or 
absence  of  hydrochloric  acid,  dilute  hydrochloric  acid  should  be 
administered  in  large  doses,  40  to  60  drops,  three  times  a  day. 
The  best  way  to  i,rive  hydrochloric  acid  is  to  add  one  teaspoonful 
of  the  dilute  acid  to  a  glassful  of  water,  to  be  taken  three  times 
a  day,,  half  an  hour  after  meals — not  the  whole  glass  at  one  time, 
but  in  three  portions  at  intervals  of  one-quarter  to  one-half  hour. 
Pepsin  is  frequently  given  in  combination  with  hydrochloric  acid, 
0.06  Gm.  (1  grain)  three  times  a  day;  it  assists  in  the  process  of 
proteolysis  by  catalysis,  that  is,  without  itself  becoming  used  up 
or  diminished  in  quantity  (see  page  258). 

Papain  and  papayotin  possess  distinct  proteolytic  properties  and 
are  active  in  neutral,  weakly  acid  or  even  alkaline  solutions.  Papa- 
yotin peptonizes  protein  foods.  These  ferments  are  indicated  in 
deficient  proteolysis  with  absence  of  hydrochloric  acid,  in  achylia 
gastrica,  and  in  gastritis  accompanied  by  subacidity  or  anacidity. 
Papayotin  and  papain  are  contra-indicated  in  ulcer  and  in  hyper- 
acidity.    The  dose  is  0.3  to  1  Gm.  (5  to  15  grains)  after  meals. 

Pancreatin. — Favorable  results  from  the  administration  of  pan- 
creatin  in  cases  of  achylia  gastrica,  subacid  and  anacid  gastritis, 
and  gastric  carcinoma,  are  often  attained.  Pancreatin  is  best 
administered  in  doses  of  1  to  2  Gm.  (15  to  30  grains)  in  combination 
with  sodium  bicarbonate,  since  it  is  active  only  in  a  neutral  or 
weakly  alkaline  medium.  The  preparation  should  be  taken  a 
quarter  of  an  hour  after  eating.  The  indication  for  pancreatin 
in  an  anacid  stomach  consists  in  the  fact  that  intestinal  digestion 
is  thus  permitted  to  begin  even  before  the  ingested  food  passes 
into  the  intestine  (see  page  262). 

Stomachics. — We  have  a  number  of  drugs  which  possess  the 
property  of  stimulating  the  appetite,  and  others  which  stimulate 
the  secretory  and  motor  functions  of  the  stomach.  Our  knowl- 
edge of  the  action  of  this  class  of  drugs  is  largely  empirical.  Loss 
of  appetite  is  an  indication  for  the  administration  of  stomachics, 
or  bitters,  as  they  are  called  (see  page  266). 

The  administration  of  the  so-called  bitter  tonics,  gentian,  con- 
durango,  quassia,  and  mix  vomica,  has  been  found  very  helpful 
in  chronic  gastritis.  The  fluidextract  of  condurango,  calumba  or 
quassia  is  to  be  taken  in  20-drop  doses  three  times  a  day.  Tinc- 
ture of  mix  vomica  may  be  prescribed  in  10-drop  doses  three  times 
a  day,  either  alone  or  in  combination  with  the  drugs  mentioned. 
These  drugs  are  best  given  a  quarter  of  an  hour  before  meals, 
in  a  little  water.  Their  physiologic  action  is  not  well  understood. 
The  favorable  effect  of  the  so-called  bitter  tonics  or  stomachics 


470         CHRONIC  GASTRITIS  AND  ACHYLIA  GASTRICA 

is  due  to  their  peculiar  taste  rather  than  to  any  direct  influence 
on  the  gastric  mucous  membrane.  The  action  of  the  bitters  begins 
with  the  sense  of  taste,  before  the  medicine  actually  reaches  the 
stomach. 

The  following  is  a  useful  combination  of  hydrochloric  acid  with 
the  bitters : 

Gm.  or  Cc. 

1$ — Tincturse  nucis  vomicae      ....       1210  5iij 

Tincturse  cinchonas  compositse      .      .       16  [0  §ss 

Acidi  hydrochlorici  diluti  ....        16  j  0  §  ss 

Aquse  destillatae       .      .      .       q.  s.  ad     120 10  §iv 

Misce. 

Sig.— One  or  two  teaspoonfuls  in  water  one-quarter  hour  before  meals. 

Orexin  is  said  to  possess  the  property  of  inducing  hunger.  It  is 
a  stomachic  (see  page  267),  but  acts  as  an  irritant  to  the  gastric 
mucosa;  it  would  therefore  be  contra-indicated  in  irritable  con- 
ditions of  the  stomach.  The  tannate  of  the  same  base  is  claimed 
to  be  less  irritating  than  the  original  product.  The  adult  dose  is 
0.3  to  1  Gm.  (5  to  15  grains)  in  capsule,  with  a  glass  of  water,  one 
or  two  hours  before  meals. 

Creosote  has  also  been  placed  among  the  stomachics.  It  causes 
energetic  peristalsis  and  slightly  increases  the  secretion.  It  is 
especially  useful  in  the  gastritis  of  tuberculosis. 

Gm.  or  Cc. 

ty— Creosoti .  12  0  5iij 

Tincturae  gentianae 20  0  3v 

Vini  xerici 800  0  Oiss 

Alcoholis 200  0  §vij 

Misce. 

Sig. — Teaspoonful  before  meals. 

Resorcinol  has  a  stimulating  effect  on  the  appetite,  as  has  been 
demonstrated  by  clinical  experience.  It  is  best  taken  in  solution, 
either  pure  or  combined  with  other  bitters: 

Gm.  or  Cc. 

1$ — Fluidextracti  condurango  ....        16(0  Bss 

Resorcinolis 4 1 0  5j 

Misce. 

Sig. — Thirty  drops  four  times  a  day. 

Nausea  and  vomiting  may  be  controlled  by  administering  cerium 
oxalate,  0.065  to  0.325  Gm.  (1  to  5  grains),  alone  or  in  combination 
with  bismuth  subnitrate  or  sodium  bicarbonate,  or  by  the  methods 
mentioned  under  Acute  Gastritis. 

The  silver  salts  are  of  great  value  in  chronic  gastritis  (see  page 
267). 

Fermentation  may  be  checked  by  the  use  of  antiseptic  agents, 
to  which  a  carminative  may  be  added  in  cases  of  flatulence.  Hy- 
drochloric acid  alone  may  be  sufficient;  if  not,  some  antiseptic 
must  be  employed,  such  as  resorcinol,  saccharin,  salicylic  acid, 
salicylate  of  bismuth,  menthol,  thymol,  benzol.     These  drugs  are 


0 

gr.  xv 

0 

3v 

0 

Si 

TREATMENT  BY  GASTRIC  LAVAGE  471 

best  given  before  meals,  cither  alone  or  in  combination  with  other 
medicaments. 

Gin.  or  Cc. 

If— Bismuthi  salicylate 20  jU  3y 

Resorcinolis 1  "  5j 

Acidi  acetylsalicylici, 

Salolis aa        2|0  3ss 

Misce  et  ft.  pulv. 

Sig.— One-third  teaspoonful  three  times  daily. 

Gm.  or  Cc. 

If— Thymolis, 

Resorcinolis aa         0 1 75  gr.  xij 

Misce  et  ft.  caps.  no.  xx. 

Sig. — One  or  two  capsules  before  meals. 

Gm.  or  Cc. 
R—  Mentholis 1 

Alcoholis 20 

Syrupi 30 

Misce. 

Sig. — One  teaspoonful  every  hour  until  relieved. 

Treatment  by  Gastric  Lavage. — Gastric  lavage  is  indicated  in 
cases  of  chronic  gastritis  in  which  there  is  mucus  secretion,  dis- 
turbance in  motility,  or  fermentation.  Mucus  should  be  removed 
by  lavage  in  the  early  morning  when  the  stomach  is  empty.  It  is 
well  to  elevate  the  irrigator  and  thus  allow  the  water  to  enter  the 
stomach  with  a  certain  amount  of  force.  In  order  to  avoid  over- 
distention,  not  more  than  eight  ounces  of  water  should  be  used 
at  one  time.  The  frequency  with  which  gastric  lavage  should  be 
practiced  must  be  determined  by  the  amount  of  mucus  in  the 
stomach  contents,  the  adequacy  of  response  to  diet  and  treat- 
ment, and  the  manner  in  which  the  patients  bear  the  washing-out 
process.  No  fixed  schedule  can  be  laid  down.  Too  frequent 
lavage  is  liable  to  do  more  harm  than  good.  It  may  be  well  to 
give  treatments  once  daily  for  a  week,  and  thereafter  two  or  three 
a  week,  soon  lessening  the  frequency. 

Mucus-dissolving  drugs  may  be  added  to  the  water  after  all 
food  particles  have  been  removed.  Alkalis  which  dissolve  mucus 
are:  Solution  of  common  salt  (1  per  cent.);  lime-water  (5  tea- 
spoonfuls  to  1  liter  of  water);  sodium  bicarbonate  (1  per  cent.); 
Fleiner's  compound  (a  mixture  of  sodium  chlorid  and  sodium  car- 
bonate in  the  proportion  of  2  to  1),  a  heaping  teaspoonful  to  2  or 
3  liters  (quarts)  of  water. 

At  the  termination  of  lavage  distilled  water  should  be  employed 
to  clear  the  stomach,  and  a  weak  solution  of  silver  nitrate  (0.1 
to  0.2  Gm.  to  30  Cc. — 2  to  3  grains  to  the  ounce)  introduced 
through  the  tube  and  allowed  to  flow  out  again.  Although 
unpleasant  in  odor,  there  is  no  agent  that  excels  ichthyol  (1  per 
cent.)  water  as  a  lavement.  Combined  with  resorcinol  it  seems 
to  exert  a  regenerating  effect  upon  epithelia,  and  is  an  excellent 
antiseptic.  If  fermentation  be  found  in  the  stomach  contents,  a 
weak  solution  of  salicylic  acid  may  be  employed  as  a  wash,  or  a 
solution  (0.1  Gm.  to  500  Cc. — 2  grains  to  the  pint)  of  potassium 


472  CHRONIC  GASTRITIS  AND  ACHYLIA  GASTRIC  A 

permanganate.  In  cases  of  disturbed  gastric  motility  lavage  with 
lukewarm  water  should  be  performed  in  the  evening,  before  the 
evening  meal,  with  the  patient  recumbent.    (See  Chapter  IX.) 

Treatment  with  Mineral  Waters. — Waters  from  the  springs  of 
Saratoga,  Congress  and  Kissingen  are  particularly  useful  in  these 
gastric  affections.  They  should  be  taken  in  small  doses  on  an 
empty  stomach.  The  artificial  waters  may  be  employed  when  it 
is  not  convenient  to  visit  the  various  resorts. 

Good  results  are  often  obtained  from  the  use  of  sodium  chlorid 
waters  in  subacid  chronic  gastritis  and  anacid  gastritis  with  func- 
tionally active  mucous  membrane.  The  increase  in  gastric  secretion 
is  frequently  so  marked  as  to  result  in  a  decided  improvement  and 
amelioration  of  symptoms  after  only  a  few  weeks'  treatment. 

Mineral  water  cures  are  also  indicated  in  those  cases  of  chronic 
gastritis  with  normal  acidity  in  which  the  patients  complain  of 
much  discomfort,  and  in  which  large  quantities  of  mucus  are 
secreted.  These  cases  are  best  treated  by  springs  similar  to 
Carlsbad. 

To  avoid  the  inhibitory  action  of  the  Carlsbad  waters  on  gastric 
secretion,  large  doses  (500  to  600  Cc.)  should  not  be  prescribed 
for  a  period  longer  than  two  weeks,  nor  smaller  doses  (200  to  300 
Cc.)  for  more  than  three  or  four  weeks.  Carlsbad  water  should 
be  taken  warm,  in  the  morning,  on  the  fasting  stomach,  slowly, 
and  in  interrupted  doses. 

Physical  Treatment, — Local  applications  of  heat,  dry  and  moist, 
are  often  of  value  in  allaying  pressure  and  pain.  Compresses, 
thermophores,  or  Leiter's  stomach  application  (the  moist  trunk 
packing),  overnight,  are  recommended.  The  Priessnitz  bandage 
is  also  very  valuable  (see  page  250).  The  Scotch  douche  is  indi- 
cated in  the  conditions  described  when  they  are  complicated  with 
atony. 

Massage  should  be  adopted  in  cases  not  complicated  with  pyloric 
stenosis,  stagnation,  or  fermentation.  Simple  atony  is  not  a  con- 
tra-indication,  but  gastric  pain  is.  As  described  in  the  chapter 
on  Massage,  this  manipulation  should  be  performed  when  the 
stomach  is  empty.  The  purpose  of  massage  is  to  improve  the 
muscle  tonicity  and  the  circulation  of  the  blood.  Massage  in 
connection  with  the  use  of  medicinal  agents  is  useful  in  some  con- 
ditions; the  drugs  are  the  simple  bitters,  as  in  the  lavage  process. 

In  chronic  gastritis  with  atony,  electric  treatment  is  indicated — 
the  extraventricular  faradic  current.  If  there  is  marked  gastralgia, 
intraventricular  galvanization  may  be  employed  (see  Chapter  X). 

When  chronic  gastric  catarrh  can  be  definitely  traced  to  con- 
gestive conditions  related  to  the  portal  system,  or  to  diseases  of 
the  liver,  heart,  or  lungs,  in  which  the  stomach  shares  in  the  portal 
engorgement,  treatment  of  such  conditions  is  especially  indicated. 
When  chronic  gastritis  is  secondary  to  other  chronic  diseases, 
these  must  receive  appropriate  treatment. 


CHAPTER  XXIV. 

MOTOR  INSUFFICIENCY. 

Atony  (Myasthenia)  ;  Dilatation  (Ischochymia,  Gastrectasis)  ; 
Pyloric  Stenosis;  Acute  Dilatation  of  the  Stomach. 

At  one  time  the  opinion  prevailed  among  gastroenterologists 
that  abnormality  in  size  or  position  of  the  stomach  was  largely 
responsible  for  motor  disturbances.  It  has  been  found,  however, 
that  greatly  dilated  and  ptotic  stomachs  do  not  of  necessity  cause 
any  disturbance  of  function.  Dilatation  of  the  stomach  assumes 
a  pathologic  importance  only  when  it  interferes  with  evacuation 
of  the  gastric  contents  into  the  intestine.  The  stomach  in  health 
should  empty  itself  of  a  small  meal  (test  breakfast)  within  an 
hour  and  a  half,  of  a  large  meal  (test  dinner)  in  seven  hours.  The 
emptying  process  is,  as  a  rule,  acomplished  within  these  limits  by 
either  atonic  or  normal  stomachs.  In  stomachs  of  both  normal 
and  abnormal  dimensions  the  emptying  period  may  be  patho- 
logically altered. 

Rosenbach  introduced  the  term  "motor  insufficiency"  to  desig- 
nate motor  disturbances  of  the  stomach.  This  term  is  now  in 
general  use.  Motor  disturbances  are  classified  as  motor  insuffi- 
ciency of  the  first  and  second  degrees. 

MOTOR  INSUFFICIENCY  OF  THE  FIRST  DEGREE  (ATONY). 

In  motor  insufficiency  of  the  first  degree  the  evacuation,  though 
complete,  is  retarded. 

Etiology.— Motor  insufficiency  of  the  first  degree  is  contingent 
upon  a  primary  relaxation  of  the  muscular  wall  of  the  stomach 
(myasthenia,  atony).  Such  muscular  relaxation  may  result  from 
irregular  modes  of  living — the  frequent  overloading  of  the  stomach 
with  food  or  distending  it  with  fluids;  the  prolonged  use  of  narcotic 
drugs  (anodynes);  or  excessive  indulgence  in  tobacco.  Idiopathic 
and  hereditary  myasthenias  have  been  observed.  Motor  insuffi- 
ciency of  the  first  degree  may  result  from  acute  or  chronic  diseases, 
grave  anemias,  infections,  loss  of  blood,  or  childbirth.  Diseases 
of  the  digestive  organs,  as  gastroenteroptosis,  chronic  gastritis, 
nervous  dyspepsia,  chronic  intestinal  catarrh,  chronic  constipation, 
portal  congestion,  or  cholelithiasis,  may  give  rise  to  primary  atony. 

Motor  insufficiency  of  the  second  degree  (dilatation)  is  due  to 
obstruction  of  the  pyloric  exit,  and  is  hypertonic  rather  than  atonic, 


474  MOTOR  INSUFFICIENCY 

the  gastric  walls  being  hypertrophied  from  the  peristaltic  move- 
ments of  the  stomach  in  its  persistent  efforts  to  empty  itself. 
Hypertrophy  of  the  pylorus  may  result  from  chronic  gastritis, 
cicatrization  of  ulcers,  slight  torsion  from  gastroptosis,  perigastric 
adhesions  and  epigastric  hernias,  hypersecretion  with  frequent 
pylorospasm,  or  repeated  injuries  in  the  region  of  the  stomach. 
The  hypertrophic  changes  in  the  pylorus  in  such  cases  are  slowly 
progressive.  These  cases,  as  a  rule,  pass  from  mechanical  motor 
insufficiency  of  the  first  degree  to  motor  insufficiency  of  the  second 
degree. 

Symptoms. — In  motor  insufficiency  of  the  first  degree  (atony) 
great  discomfort  may  be  experienced  on  the  ingestion  of  food; 
the  pressure  symptoms  and  feeling  of  fulness  may  persist  for  several 
hours,  or  in  severe  cases  as  long  as  there  is  food  in  the  stomach. 
Patients  are  apt  to  be  annoyed  by  eructations,  with  pyrosis,  when 
hyperacidity  is  present.  The  so-called  "stomach  dizziness"  is 
sometimes  experienced  in  gastric  atony  complicated  with  con- 
stipation. Patients  may  complain  of  many  symptoms  of  neur- 
asthenia, such  as  fulness  in  the  head,  headache,  palpitation  of  the 
heart,  backache,  or  hypersensitiveness  on  mental  or  physical  effort. 
The  physician  should  endeavor  to  differentiate  clearly  between 
motor  insufficiency  of  the  first  degree  (atony)  and  motor  insuffi- 
ciency of  the  second  degree  (dilatation)  induced  directly  by  pyloric 
stenosis. 

Diagnosis.— Gastroptosis  and  atony  occur  frequently  in  the 
same  individual.  Gastroptosis  may  sometimes  be  diagnosticated 
by  inspection  when  the  abdominal  walls  are  thin  and  relaxed  and 
the  stomach  is  in  a  condition  of  peristaltic  movement.  Permanent 
and  absolute  dilatation  of  the  stomach  does  not  occur  in  primary 
atony.  The  atonic  muscles  may,  however,  be  so  greatly  distended 
by  the  pressure  of  food  as  to  constitute  a  condition  of  transient 
dilatation  of  the  stomach.  Should  a  person  with  a  normal  mus- 
culature drink  a  sufficient  quantity  of  water,  the  inferior  border 
of  the  stomach  may  descend  to  the  level  of  the  umbilicus,  as  shown 
by  the  area  of  gastric  dulness.  The  atonic  stomach,  on  the  other 
hand,  may  be  so  distended  by  fluids  as  to  throw  the  lower  border 
below  the  umbilicus.  Splashing  sounds  elicited  when  the  stomach 
should  be  empty  go  to  confirm  a  diagnosis  of  atony.  The  stomach 
in  a  condition  of  atony  contains  food  remnants  six  or  seven  hours 
after  the  ingestion  of  a  test  dinner.  It,  however,  empties  itself 
completely  during  the  night,  after  a  test  supper.  One  hour  and 
a  half  after  a  test  breakfast  the  atonic  stomach  is  found  to  contain 
food  residue  (see  page  95). 

The  motility  and  power  of  evacuation  of  the  stomach  may  be 
demonstrated  by  Roentgen  fluoroscopy.  Gastric  tonus  and  atony 
(Plate  XIII,  Figs.  3  and  4)  can  be  readily  made  out  by  means  of 
the  Roentgen  ray  (see  Chapter  V). 


MOTOR  INSUFFICIENCY  OF  THE  FIRST  DEGREE         475 

Examination  of  the  stomach  contents  withdrawn  by  means 
of  the  stomach  tube  reveals,  in  atonic  conditions,  the  presence  of 
free  hydrochloric  acid  in  varying  quantities,  depending  upon 
whether  the  case  is  one  of  simple  non-complicated  atony  or  a 
complication  of  atony  with  gastritis  or  hypersecretion.  Should 
simple  atony  be  protracted  for  some  length  of  time,  the  result  may 
be  diminished  acid  secretion.  In  the  absence  of  gastritis  and 
hypersecretion  the  acidity  usually  remains  normal  for  a  long  time, 
and  the  secretion  of  pepsin  and  rennin  remains  normal  for  a  much 
longer  period.  Constipation  frequently  accompanies  atony  of  the 
stomach. 

Treatment. — The  treatment  of  motor  insufficiency  of  the  first 
degree  should  tend  to  prevent  overdistention  of  the  stomach  and 
at  the  same  time  improve  the  muscle  tonus.  Much  may  be  accom- 
plished by  suitable  diet,  which  should  be  so  selected  as  to  make 
the  least  demand  upon  the  motor  activity  of  the  stomach.  The 
meals  should  be  small  in  quantity  and  comparatively  frequent.  In 
the  atonic  as  in  the  normal  stomach  the  liquid  portion  of  the  food 
passes  into  the  duodenum  first,  then  the  semisolid,  and  lastly  the 
solid  residues  of  food.  Water  leaves  the  atonic  stomach  with 
marked  rapidity,  so  that  the  amount  of  water  in  the  tissues  of  the 
body  is  fairly  constant.  Considering  the  ease  with  which  the 
stomach  empties  itself  of  liquid  and  semiliquid  foods,  these  should 
constitute  a  large  proportion  of  the  diet  in  atonic  states.  The 
stomach  can  take  care  of  large  quantities  of  liq  rids  so  long  as 
they  are  ingested  regularly  and  in  small  amounts. 

Milk  holds  first  place  in  the  list  of  foods  for  the  dietetic  treatment 
of  gastric  atony.  In  selected  cases  the  milk  cure,  combined  with 
rest  in  bed,  may  be  employed  for  several  days.  By  administering 
at  intervals  of  two  hours  250  to  300  Cc.  (§viij-x)  of  milk,  2000 
Cc.  (2  quarts)  may  be  taken  during  the  twenty-four  hours  with- 
out causing  overdistention  of  the  stomach.  In  addition  to  milk 
a  variety  of  preparations  with  milk  may  be  employed,  as  cocoa, 
tea,  rice,  oatmeal,  and  corn  starch.  To  prevent  fermentation,  pure 
salicylic  acid,  0.3  Gm.  (5  grains),  should  be  thoroughly  mixed  with 
a  small  quantity  of  cold  milk,  the  mixture  added  to  the  daily 
quantity  of  milk  (a  liter  and  a  half),  and  the  whole  boiled.  Butter- 
milk, kefir  and  peptonized  milk  are  useful  adjuncts  to  the  diet. 

Diet  in  Normal  Acidity,  Hyperacidity  and  Hypersecretion. — In 
cases  of  gastric  atony  in  which  the  acidity  is  normal  or  higher  than 
normal,  and  in  hypersecretion,  a  strictly  protein-fat  diet,  to  obviate 
the  carbohydrate  fermentation  which  would  otherwise  result  from 
insufficient  amylolysis,  is  to  be  prescribed.  Since  protein  is  quite 
thoroughly  digested  in  such  cases,  it  is  not  necessary  that  it  be 
taken  in  liquid  or  semiliquid  form;  but  should  gastric  ulcer  or 
erosion  be  suspected,  the  nutriment  must  be  liquid.  It  is  neces- 
sary that  the  protein  food  be  thoroughly  cooked.    An  extensive 


476  MOTOR  INSUFFICIENCY 

variety  of  meat  and  fowl,  and  dishes  prepared  from  them,  as  well 
as  jellies,  eggs,  and  soft  cheese,  may  be  prescribed. 

Fat,  owing  to  its  power  of  diminishing  secretion,  is  indicated  in 
hyperacid  conditions.  Its  use  is  distinctly  advantageous  in  the 
treatment  of  atony.  Fat  is  not  classed  among  the  so-called 
"heavy*'  foods.  Motor  insufficiency  with  increased  or  normal 
secretion  is  benefited,  and  in  some  cases  a  radical  cure  is  accom- 
plished, by  a  protein-fat  diet.  All  kinds  of  fat  with  a  low  melting- 
point  and  pure  in  quality  may  be  employed.  Butter,  cream  and 
olive  oil  are  suitable  forms  of  fat;  but  fat  pork  and  the  fat  of  roast 
duck  or  goose  should  be  avoided. 

In  cases  of  well-marked  atony  the  physician  commences  treat- 
ment with  an  exclusive  protein-fat  diet,  and  later  adds  small  quan- 
tities of  carbohydrates  so  that  he  has  a  high  protein-fat  and  low 
carbohydrate  combination.  The  carbohydrate  constituent  con- 
sists of  toast,  zwieback,  biscuits,  rice,  leguminous  flours  prepared 
in  the  form  of  gruels,  soups,  mashed  potatoes — each  prepared  with 
as  large  a  quantity  of  milk  and  butter  as  can  be  used.  Green 
vegetables  should  be  avoided. 

Diet  in  Subacidity  and  Anacidity. — The  principles  underlying  the 
dietetic  treatment  of  chronic  gastritis  apply  also  in  this  condition 
(see  Chapter  XXIII) .  The  diet  should  be  in  all  cases  liquid  or 
'  semiliquid.  It  should  contain  a  large  admixture  of  fat.  Meats, 
if  eaten,  should  be  taken  in  a  very  finely  subdivided  condition,  and 
eggs  in  the  form  of  the  light  egg  dishes.  Carbohydrates  should 
be  taken  in  the  form  of  flour  soups  or  leguminous  soups  and  vege- 
table purees,  all  of  which  should  be  prepared  with  as  much  butter 
and  milk  as  possible.  Milk  is  the  best  beverage  in  this  class  of 
cases.  Alcohol  should  not  be  given  in  gastric  atony  except  in  the 
form  of  small  quantities  of  mild  claret.  Coffee  should  be  inter- 
dicted, and  tea  given  only  in  combination  with  milk.  After  each 
meal  the  patient  should  rest  in  the  recumbent  position,  preferably 
on  the  right  side.  If  thirst,  be  a  troublesome  feature  of  the  disease, 
it  may  be  allayed  by  the  daily  administration  of  two  or  three 
enemata  of  physiologic  salt  solution  of  150  to  200  Cc.  (!5v~vij) 
each,  thus  avoiding  distention  of  the  stomach. 

Lavage  of  the  Stomach. — Lavage  of  the  stomach  is  not  indicated 
in  atony,  inasmuch  as  the  stomach  evacuates  itself  completely, 
though  perhaps  tardily.  Atony  complicated  with  hypersecretion 
may  be  benefited  by  an  occasional  lavage.  The  so-called  gastric 
douche  has  been  recommended  in  atony,  and  is  said  to  have  the 
effect  of  strengthening  the  muscular  coats.  When  the  gastric 
douche  is  employed  the  rinsing  may  be  performed  with  the  aid 
of  Rosenheim's  tube  (Fig.  21),  physiologic  salt  solution  being  used 
in  subacidity  and  Carlsbad  salt  solution  in  hyperacidity;  the  tem- 
perature of  the  liquid  may  be  lowered  gradually  to  54°  F.  Should 
the  patient  have  little  or  no  appetite,  the  washing  process  may 


MOTOR  INSUFFICIENCY  OF  THE  FIRST  DEGREE         177 

be  accomplished  with  an  infusion  of  hops  t<>  which  has  been  added 
a  little  fluidextract  of  condurango  for  its  stimulant  effecl  upon  the 

sense  of  hunger  (see  page  199). 

Medicinal  Treatment. — The  alkalis  are  indicated  in  cases  of 
atony  accompanied  by  hyperacidity  or  hypersecretion  as  a  com- 
plication. The  most  suitable  of  these  have  been  found  to  be 
magnesium  oxid  and  the  double  phosphate  of  ammonium  and 
magnesium.  Bicarbonate  of  sodium  has  the  disadvantage  of  pro- 
ducing, in  combination  with  the  normal  acid  secretion,  too  much 
carbon  dioxid,  which  causes  overdistention  of  the  stomach.  Atro- 
pin  is  employed  for  its  inhibitory  effect  in  cases  of  simple  non- 
complicated hyperacidity  (see  Chapter  XX).  Hydrochloric  acid 
in  combination  with  pepsin  is  indicated  in  subacidity  and  an  acid- 
ity. In  the  presence  of  fermentation  such  antifermentative  drugs 
as  bismuth,  resorcinol,  benzosol,  salicylic  acid  and  menthol  are  to 
be  employed.  Strychnin  sulphate,  0.001  to  0.006  Gm.  {-$-$  to  yo 
grain),  hypodermically,  or  extract  of  nux  vomica,  0.008  to  0.05  Gm. 
(I  to  1  grain),  will  increase  the  muscular  tone. 

Gm.  or  Cc. 
1$ — Extract i  nucis  vomicae        ....       0|1  gr.  iss 

Extracti  gentianae  radicis,  q.  s. 

Misce  et  ft.  pil.  no.  xxx. 
Sig. — One  or  two  pills  three  times  a  day,  after  meals. 

Physical  Treatment. — Gastric  atony  has  been  benefited  by  the 
employment  of  hydrotherapeutic  measures.  Muscular  tonicity 
has  been  increased  by  means  of  the  Scotch  douche  and  cold  com- 
presses applied  over  the  gastric  region.  Massage  is  indicated  in 
all  cases  of  atony  uncomplicated  writh  dilatation  or  organic  sten- 
osis, hyperacidity  or  hypersecretion;  it  may  be  employed  even  in 
ptosis  of  the  stomach.  The  purpose  of  massage  is  to  improve 
the  muscular  tone  and  aid  in  the  expulsion  of  the  gastric  contents 
into  the  duodenum.  When  the  purpose  is  to  improve  muscular 
tonicity,  massage  should  be  undertaken  when  the  stomach  is  empty; 
to  aid  in  emptying  the  stomach  it  is,  of  course,  performed  when 
that  viscus  is  filled  with  food.  Electric  treatment,  consisting  of 
intra-  and  extraventricular  faradization,  is  also  employed  as  a 
means  of  improving  the  muscular  tone.  Massage  may  be  employed 
in  conjunction  with  electric  treatment,  or  electricity  and  general 
massage  may  be  employed  alternately,  to  be  followed  by  abdominal 
massage  in  cases  of  arrested  intestinal  peristalsis  (see  Chapter  X). 

Treatment  with  Mineral  Waters. — The  use  of  mineral  waters 
has  been  found  advantageous  in  the  treatment  of  very  mild 
cases  of  atony — being  selected  according  to  the  condition  of  the 
gastric  secretion;  in  hyperacidity  and  in  hypersecretion  the  Sara- 
toga waters  and  waters  from  alkaline-carbonate  springs  should 
be  employed,  while,  on  the  other  hand,  sodium  chlorid  waters 
should  be  used  in  subacidity  and  anacidity.    The  mineral-water 


478  MOTOR  INSUFFICIENCY 

treatment  should  be  employed  with  great  caution,  and  the  waters 
prescribed  in  limited  quantities  in  order  to  avoid  overloading  the 
stomach.  Mineral  waters  should  not  be  used  in  these  cases  when 
the  patients  complain  of  more  or  less  severe  symptoms,  but  the 
patients  should  be  sent  to  the  seashore  for  ocean  baths  or  advised 
to  make  climatic  changes  (see  page  252). 

In  cases  of  atony  in  which  gastric  ulcer,  gastritis,  ptosis,  or 
neurasthenia  is  known  to  be  present  as  a  positive  factor,  the  com- 
plicating condition  should  receive  treatment  as  outlined  in  the 
respective  sections  of  this  work. 

MOTOR  INSUFFICIENCY  OF  THE  SECOND  DEGREE 
(DILATATION). 

Motor  insufficiency  of  the  second  degree  is  a  chronic  condition 
in  which  the  stomach  has  lost  entirely  the  ability  to  expel  its  con- 
tents; that  is,  food  residues  remain  in  the  stomach  permanently 
(stagnation);  and  as  a  consequence  of  this  chronic  condition  of 
gastric  insufficiency  we  have  dilatation  of  the  stomach  (ischochy- 
mia,  gastrectasis) .     (Plate  XIV,  Fig.  2.) 

Etiology. — The  cause  of  motor  insufficiency  of  the  second  degree 
may  be  either  trauma  of  the  muscle  fibers  of  the  stomach  or  pyloric 
stenosis.  It  is  possible  that  motor  insufficiency  of  the  first  degree 
(atony)  may  in  time  be  transformed  into  motor  insufficiency  of 
the  second  degree  (dilatation)  with  stagnation  of  the  stomach 
contents.  Careful  clinical  and  anatomic  examinations  have  shown 
us  that  stenosis  of  the  pylorus  is  the  cause  of  nearly  every  case 
of  motor  insufficiency  of  the  second  degree.  The  lumen  of  the 
pylorus  may  be  narrowed  from  the  inside  or  from  the  outside;  it 
may  be  cicatrized  and  contracted  from  the  healing  of  gastric  ulcers, 
or  there  may  be  cicatricial  tissue  as  a  result  of  healed  perforations 
from  biliary  calculi.  Next  to  ulcer,  carcinoma  of  the  pylorus  is 
the  most  important  and  dangerous  cause  of  occlusion  of  the  pyloric 
lumen.  The  differentiation  is  often  a  very  difficult  one.  A  tumor 
may  be  so  small  and  smooth  as  to  entirely  escape  palpation,  and 
there  may  be  nothing  but  the  motor  disturbance  to  indicate 
stenosis.  Polypi  and  myomata  of  the  pylorus  are  occasionally  met 
with.     Foreign  bodies  may  block  the  pyloric  exit. 

Adhesions  may  change  the  lumen  of  the  pylorus  by  displacement 
and  distortion.  Cholecystitis  may  lead  to  the  same  result,  as  it 
may  impede  the  motility  of  the  pylorus  by  adhesions,  forming  the 
cobwebs  of  Morris.  I  recall  a  case  of  gastric  retention  where  all 
the  clinical  symptoms  pointed  to  a  carcinomatous  affection.  Stag- 
nation was  present,  with  lactic  acid,  pus  and  blood  in  the  gastric 
contents.  At  operation  the  stomach  was  dilated,  but  there  was  no 
tumor.  Instead,  there  was  found  an  infected  gall  bladder,  with 
gallstones  and  adhesions.  The  gallstones  were  removed,  the  gall 
bladder  drained,  and  the  patient  made  a  complete  recovery. 


MOTOR  INSUFFICIENCY  OF  THE  SECOND  DEGREE        479 

Spastic  stenosis  of  the  pylorus  (pylorospasm)  is  by  no  means 
a  rare  condition;  it  is  caused  by  the  irritating  effect  of  the  ingesta 
upon  erosion  or  fissure  of  the  pylorus,  or  by  an  abnormally  high 
degree  of  gastric  acidity  (hypersecretion).  This  kind  of  closure  of 
the  pylorus  is  at  first  periodic.  When,  however,  the  attacks 
become  more  frequent,  the  effect  is  permanent  stenosis.  Spastic 
closure  of  the  pylorus  may  also  result  from  hysterical  crises. 
Chronic  hyperplasia  of  the  gastric  mucous  membrane  (etat  mame- 
Umne)  and  hypertrophy  of  the  muscles  in  the  region  of  the  pylorus 
in  chronic  gastritis  and  cirrhosis  ventriculi  also  cause  stenosis. 
Syphilis  may  become  an  etiologic  factor  in  chronic  hypertrophy  of 
the  pylorus. 

Adhesions  of  the  stomach  to  neighboring  organs  or  to  abdominal 
tumors  may  cause  pyloric  stenosis  by  compression  or  by  bending 
the  pylorus  upon  itself. 

A  valuable  device  for  ascertaining  the  patency  of  the  pylorus 
is  the  duodenal  bucket  (Fig.  8).  Fastened  to  a  silk  string  75 
centimeters  long,  it  is  swallowed  by  the  patient  and  allowed  to 
remain  overnight.  Upon  its  removal  the  contents  are  examined 
for  pancreatic  ferment — which,  if  found,  assures  us  that  the  bucket 
has  passed  through  the  pylorus  and  that  therefore  the  pylorus  is 
patent  (see  page  399).  Einhorn  has  also  drawn  attention  to  an 
important  diagnostic  point  in  this  connection;  if  there  is  an  ulcer 
in  the  tract  covered,  the  string  will  be  discolored  by  blood  and 
this  will  give  us  a  clue  to  the  site  of  the  ulcer  (Fig.  84). 

Symptoms. — As  soon  as  pyloric  stenosis  begins  to  interfere  with 
the  free  passage  of  food  from  the  stomach  to  the  duodenum,  symp- 
toms of  greater  or  less  severity  manifest  themselves.  They  may  at 
first  be  the  symptoms  of  motor  insufficiency  of  the  first  degree,  such 
as  pressure  and  a  sense  of  fulness  after  eating;  and  the  desire  for 
food  is  easily  satiated.  Eventually  the  pressure  symptoms  become 
aggravated  in  proportion  to  the  increasing  stenosis  of  the  pylorus, 
the  stomach  becomes  distended,  and  pain  is  caused  by  the  inces- 
sant attempt  of  the  gastric  muscles  to  overcome  the  obstruction 
to  the  pyloric  exit.  When  the  obstruction  becomes  so  pronounced 
as  to  effect  a  closure  of  the  pylorus,  the  food  remains  in  the  stom- 
ach and  stagnation  results.  By  far  the  most  important  symptom 
of  gastric  retention  is  vomiting,  which  is  usually  profuse.  At  first 
it  does  not  occur  often,  but  the  intervals  continue  to  grow  shorter 
until  at  last  large  quantities,  apparently  larger  than  those  ingested, 
are  vomited  every  day.  The  vomitus  will  contain  food  remnants 
many  days  old,  for  food  that  is  not  readily  digestible  may  remain 
in  the  stomach  for  days. 

On  standing  in  a  sedimentation  glass,  the  vomitus  usually  sepa- 
rates into  three  layers.  The  solid  particles,  being  the  heaviest, 
sink  to  the  bottom;  the  fluid  above  is  cloudy,  and  the  top  layer 
consists  of  more  or  less  viscid  mucus  permeated  by  gas  bubbles. 


480  MOTOR  INSUFFICIENCY 

This  stratification  in  three  layers  is  thoroughly  characteristic  of 
all  forms  of  gastric  retention  which  are  due  to  or  associated  with 
stenosis  of  the  pylorus. 

The  vomiting  of  malignant  stenosis  is  totally  different,  especially 
after  the  affection  has  reached  an  advanced  stage.  The  vomitus 
is  no  longer  dilute,  but  viscid — like  a  thick  soup — and  permeated 
by  mucous  masses,  everything  being  so  closely  intermixed  that 
it  is  difficult  to  diffuse  the  mass  with  water.  The  odor  is  peculiarly 
mouldy,  sometimes  absolutely  putrid,  like  decomposed  tissue. 
The  food  remnants  are  almost  unchanged.  Meat  can  be  found 
days  after  being  taken  into  the  stomach,  and  even  farinaceous 
food  is  undigested.  The  appearance  of  the  gastric  contents  is  so 
characteristic  as  to  be  almost  sufficient  of  itself  to  determine  the 
diagnosis. 

The  appetite,  fair  at  first,  diminishes  with  the  increasing  stag- 
nation. Patients  in  the  meantime  complain  of  severe  thirst.  The 
body  becomes  impoverished  for  fluid,  since  the  stomach  cannot 
absorb  water.  This  condition  is  indicated  by  the  remarkably 
small  quantities  of  urine  excreted  and  by  hard  impacted  fecal 
matter.  The  pyloric  stenosis  is  accompanied  by  pronounced 
emaciation.  The  skin  is  dry  and  drawn  because  of  the  small 
amount  of  water  in  the  tissues.  Patients,  as  a  rule,  complain  of 
dizziness,  lassitude,  inability  to  work,  and  somnolence.  When 
the  decomposed  gastric  contents  pass  into  the  intestine,  pronounced 
gaseous  fermentation  arises,  producing  distention  of  the  bowel, 
with  abdominal  pains  and  headache.  Gastrogenic  diarrhea  may 
be  brought  on  by  the  decomposed  gastric  contents  irritating  the 
bowel  (see  Chapter  XXXVIII). 

Diagnosis. — Dilatation  of  the  stomach  from  stenosis  of  the 
pylorus  may  assume  marked  dimensions.  It  is  a  matter  of  diag- 
nostic importance  to  ascertain  the  degree  of  dilatation.  A  dilated 
stomach  has  a  characteristic  form  which  is  easily  demonstrated 
by  the  Roentgen  ray  (see  Chapter  V).  In  obstruction  of  the 
pylorus  the  shadow  near  the  stenosis  is  round  and  blunt  (see  Plate 
XVI,  Fig.  1).  Apart  from  the  anamnesis,  the  diagnosis  is  facili- 
tated by  the  presence  of  abnormal  peristaltic  movements  (visible 
contractions)  of  the  stomach,  by  the  signs  of  motor  insufficiency 
of  the  second  degree,  and  by  examination  of  the  stomach  contents. 
Motor  insufficiency  is  indicated  by  the  nature  of  the  food  remnants 
in  the  stomach  in  the  morning  after  a  night's  fast.  Fermentation 
is  always  present,  its  extent  depending  upon  the  degree  of  stenosis 
of  the  pylorus.  In  benign  stenosis  the  stomach  contents  are  acid, 
owing  to  the  presence  of  hydrochloric  and  organic  acids,  such  as 
acetic  and  butyric,  the  latter  resulting  from  fermentation;  sul- 
phuretted hydrogen  gas  also  is  present,  arising  from  the  decom- 
position of  protein  matter.  In  malignant  stenosis  (carcinoma), 
lactic  acid  predominates,  but  hydrochloric  acid  may  also  be  present 


MOTOR  INSUFFICIENCY  OF  THE  SECOND  DEGREE  |S| 

for  a  considerable  time,  especially  at  the  beginning  of  the  carci- 
nomatous process.  The  finding  of  sarcinee  is  of  diagnostic  signifi- 
cance in  benign  stenosis  of  the  pylorus;  the  presence  of  lactic  acid 
bacilli  will  aid  in  the  confirmation  of  malignant  stenosis.  When 
the  stagnating  gastric  contents  become  strongly  acid,  the  urine 
may  be  found  to  be  alkaline  in  reaction,  with  a  resultant  lowering 
of  the  percentage  of  chlorids  in  the  body.  The  presence  of  bile 
in  the  gastric  contents  favors  a  diagnosis  of  stenosis  of  the  duo- 
denum. Gastric  hemorrhage  may  occur  in  either  malignant  or 
benign  stenosis  of  the  pylorus.  The  stomach  contents  and  the  test- 
diet  stool  are  characteristic  (see  page  95  and  Chapter  IV). 

Treatment. — The  treatment  of  this  condition  is  essentially  dietetic. 
The  diet  should  be  such  as  to  make  the  least  possible  demand  upon 
the  motor  activity  of  the  stomach.  It  should  not  be  larger  in 
amount  than  is  absolutely  essential,  and  it  should  be  ingested  in 
a  form  most  easy  of  expulsion  from  the  stomach  into  the  duo- 
denum. The  diet  in  this  class  of  cases  resembles  that  advised  in 
atony.  The  condition  of  the  secretory  function  must  be  carefully 
estimated.  Fat  may  be  prescribed  along  with  protein  when  the 
secretion  of  hydrochloric  acid  is  either  normal  or  above  normal. 
Carbohydrates  I  prescribe  in  as  small  amounts  as  can  be  got  along 
with,  and  give  them  in  the  most  soluble  form  possible,  preferably 
dextrinized.  The  artificial  protein  preparations  are  indicated  in 
this  condition.  Green  vegetables  should  be  avoided,  even  in  the 
form  of  purees.  The  food  should  be  liquid  or  semisolid  in  con- 
sistency. 

Beverages  should  be  restricted  to  the  lowest  practicable  limit, 
and  should  consist  of  drinks  with  a  nutritive  value,  such  as  milk 
or  cocoa.  If  the  patient  can  tolerate  it,  the  oil  cure  recommended 
by  Cohnheim  may  be  employed  with  advantage  (see  page  273). 
This  consists  in  the  patient  drinking,  or  in  having  introduced  by 
means  of  the  stomach  tube,  three  times  a  day,  before  meals,  50 
to  60  Cc.  (giss-ij)  of  pure  olive  oil,  at  body  temperature.  If 
lavage  is  a  part  of  the  general  treatment,  100  to  200  Cc.  (5iij- 
vij)  of  oil  may  be  introduced  at  the  conclusion  of  each  lavage,  when 
the  stomach  will  be  sure  to  be  empty.  The  oil  has  an  antispas- 
modic action  and  serves  as  a  coating,  being  especially  useful  if 
fissures,  erosions  or  ulcers  are  present.  Oil  has  the  additional 
advantage  of  diminishing  the  secretion  in  cases  of  hypersecretion 
and  hyperacidity.  The  oil  treatment  is  recommended  particularly 
in  spastic  contraction  of  the  pylorus. 

To  Allay  the  Thirst.  —  An  attempt  should  be  made  to  allay 
thirst,  which  is  often  very  distressing,  by  moistening  the  lips  and 
the  cavity  of  the  mouth.  The  mouth  should  be  frequently  rinsed 
with  cold  aromatic  waters.  Small  pieces  of  ice  may  be  given,  but 
the  water  should  not  be  swrallowed.  When  this  method  of  allaying 
the  thirst  fails,  recourse  must  be  had  to  rectal  enemata.  Water 
31 


482  MOTOR  INSUFFICIENCY 

is  readily  absorbed  by  the  rectum  and  colon,  especially  when  the 
body  has  become  much  impoverished  for  want  of  fluids.  Eight 
to  ten  ounces  of  lukewarm  water  should  be  allowed  to  flow  into 
the  rectum  through  a  soft-rubber  tube,  preferably  by  the  drop 
method  (see  page  239\  so  that  the  patient  may  retain  as  much 
of  the  fluid  as  possible  until  absorption  takes  place.  Normal  salt 
solution  may  be  used  instead  of  pure  water. 

Rectal  Alimentation. — When  food  cannot  be  retained  in  the 
stomach,  rectal  alimentation  may  be  employed  with  advantage 
and  continued  exclusively  for  eight  to  fourteen  days  (see  page 
243) .  The  physiologic  rest  of  the  stomach  afforded  by  this  method 
of  feeding  is  usually  followed  by  marked  improvement  in  the 
gastric  symptoms;  the  improvement  is  often  so  pronounced  as  to 
permit  of  a  resumption  of  feeding  by  mouth.  Feeding  by  mouth 
should,  however,  be  resumed  very  gradually,  and  as  the  power  of 
gastric  digestion  increases  the  number  and  quantity  of  nutrient 
enemata  may  be  as  gradually  decreased. 

Subcutaneous  Nutrition.- — When  rectal  alimentation  fails,  sub- 
cutaneous nutrition  remains  as  a  last  resort.  It  has  been  shown 
that  grape-sugar  solutions  are  well  borne  when  administered 
hypodermically;  the  injection  is,  however,  accompanied  by  much 
pain.  About  100  Cc.  (Siij)  of  a  10-per-cent.  solution  of  grape- 
sugar  may  be  introduced  by  means  of  a  cannula  connected  with 
a  funnel.  Injections  of  oil,  such  as  olive  oil  or  oil  of  sesame,  are 
said  to  be  less  painful.  Oil  may  be  injected  in  quantities  up  to 
100  Cc.  by  means  of  a  funnel  and  cannula  or  the  syringe.  Nutri- 
tion by  hypodermic  injection  is  only  to  be  thought  of  when  no 
other  method  of  feeding  is  practicable.  Subcutaneous  injection  of 
water  (hypodermoclysis)  in  cases  in  which  the  quantity  of  water 
in  the  tissues  has  become  greatly  reduced  has  been  found  very 
efficacious;  the  water  is  usually  given  as  normal  salt  solution;  from 
1  to  1|  liters  (2  to  3  pints)  may  be  administered,  and  the  injection 
repeated. 

Treatment  by  Lavage. — Routine  washing  of  the  stomach  is  indi- 
cated in  all  cases  of  motor  insufficiency  in  which  that  viscus  does 
not  completely  empty  itself  of  its  contents  during  the  night's  fast. 
The  stomach  should  be  emptied  and  relieved  of  the  retained  food 
remnants.  The  most  satisfactory  results  are  obtained  by  the  use 
of  gastric  lavage  in  the  rare  forms  of  atonic  stagnation  with  insuf- 
ficiency, and  in  spastic  stenosis  of  the  pylorus.  After  a  continued 
course  of  gastric  lavage  the  dilated  stomach  has  been  found  to 
approximate  the  normal,  and  the  gastric  muscles  have  shown 
marked  improvement  in  tone;  especially  is  this  the  case  in  benign 
stenosis  of  the  pylorus.  We  do  not  get  this  improvement  in  cases 
of  malignant  stenosis.  It  is  sometimes  possible,  however,  by 
means  of  lavage,  to  improve  the  pyloritis  and  thus  arrest  the 
progress  of  pyloric  stenosis.     A  proper  time  for  the  performance  of 


MOTOR  INSUFFICIENCY  OF  THE  SECOND  DEGREE        483 

lavage  is  in  the  evening,  before  supper,  so  that  the  stomach  may 
be  relieved  of  undigested  and  decomposed  food  remnants  before 
another  meal  is  taken. 

Gastric  lavage  is  usually  followed  by  a  marked  amelioration 
of  the  subjective  symptoms.  The  appetite  increases,  pain  ceases, 
vomiting  disappears,  and  thirst  is  diminished,  while  at  the  same 
time  the  urinary  secretion  becomes  normal  in  amount.  All  this 
improvement  should  take  place  within  three  or  four  weeks, 
otherwise  the  prognosis  is  not  good. 

Mechanical  Treatment. — When  dilatation  and  ptosis  exist,  im- 
provement sometimes  follows  the  application  of  properly  fitting 
abdominal  bandages  which  assure  support  to  the  stomach.  The 
reader  is  referred  to  the  chapter  on  Gastroenteroptosis  for  details 
in  regard  to  this  mechanical  treatment. 

Physical  Treatment. — The  galvanic  current  is  indicated  in  those 
rare  forms  of  motor  insufficiency  of  the  second  degree  in  which 
there  is  no  obstruction  at  the  pylorus.  In  pyloric  stenosis  the 
peristaltic  movements  of  the  stomach  are  accelerated,  thus  ren- 
dering unnecessary  any  extraneous  aid  for  the  purpose  of  improving 
muscular  tone.  Massage  of  the  stomach  may  be  practiced  in  the 
treatment  of  atonic  varieties  of  motor  insufficiency  of  the  second 
degree.  It  should  not  be  employed  when  the  stomach  contains 
food  remnants,  but  only  after  the  decomposing  material  has  been 
removed  by  lavage. 

Mineral  Waters. — The  mineral-water  cures,  so  called,  are  contra- 
indicated  in  motor  insufficiency  of  the  second  degree  in  the  pres- 
ence of  stagnation,  inasmuch  as  their  employment  would  only  serve 
to  increase  the  amount  of  fluid  in  the  overburdened  stomach. 

Medicinal  Treatment. — The  internal  administration  of  drugs  is 
probably  the  least  important  factor  in  the  treatment  of  motor 
insufficiency  with  stagnation,  since  the  drugs  must  come  in  con- 
tact with  decomposed  food  remnants  in  the  stomach.  Strychnin 
sulphate  may  be  administered  hypodermically.  As  an  antifer- 
mentative  in  cases  of  gastric  distention,  either  sodium  salicylate 
or  magnesium  salicylate,  1  to  3  Gm.  (15  to  45  grains)  in  divided 
doses  for  the  twenty-four  hours,  is  useful.  One  Cc.  (15  minims) 
of  dilute  hydrochloric  acid  may  be  administered  several  times 
a  day  for  an  extended  period,  in  order  to  counteract  fermenta- 
tion caused  by  the  presence  of  lactic  and  butyric  acids.  The 
vegetable  bitters,  such  as  condurango  and  quassia,  are  sometimes 
useful.  In  spastic  contraction  of  the  pylorus  brought  on  by  hyper- 
acidity and  hypersecretion,  alkalis,  astringents  or  atropin  sulphate 
may  be  administered  as  indicated  in  hyperacid  conditions  of  secre- 
tion. The  latter  drug  should  be  administered  immediately  after 
gastric  lavage,  in  order  that  it  may  come  in  contact  with  the  empty 
stomach,  thus  ensuring  absorption. 

When  pyloric  stenosis  can  be  traced  to  a  syphilitic  cause,  specific 


484  MOTOR  INSUFFICIENCY 

treatment  will  be  productive  of  good  results.  In  cases  where  the 
stenosis  is  due  to  gastric  carcinoma,  little  can  be  hoped  for  from  a 
course  of  internal  medication. 

Some  writers  have  reported  favorable  results  from  the  adminis- 
tration of  thiosinamin.  Thiosinamin  has  been  superseded  by  the 
discovery,  by  Mendel,  of  an  analogous  preparation,  fibrolysin 
(thiosinamin  and  sodium  salicylate).  Fibrolysin  is  supplied,  in 
brown  glass  bulbs,  sterile  and  ready  for  use;  each  bulb  or  ampoule 
contains  2.3  Cc.  of  a  solution  of  1|  parts  fibrolysin  to  8|  parts 
distilled  water,  corresponding  to  0.2  Gm.  thiosinamin.  Fibrolysin 
should  be  injected  in  the  intrascapular  region  directly  into  the 
muscles.  The  effect  is  similar  to  that  of  thiosinamin,  namely,  the 
softening  and  rendering  elastic  of  cicatricial  tissue,  thereby  prevent- 
ing the  contraction  which  results  from  cicatrix  formation.  I  would 
advise  that  a  trial  be  made  of  these  agents,  especially  in  compara- 
tively vigorous  patients  who  are  able  to  take  and  retain  nourish- 
ment by  mouth.  In  severe  cases,  however,  in  which  stenosis  is 
well  marked  and  associated  with  emesis  and  pronounced  emacia- 
tion, such  treatment  will  not  be  successful;  to  adopt  it  would 
simply  be  temporizing  instead  of  giving  the  patient  the  benefit  of 
early  surgical  intervention. 

Treatment  of  Stenosis  of  the  Pylorus. — We  should  direct  our 
treatment  likewise  to  pyloric  stenosis.  Success  is  often  attained 
by  combating  the  causes  of  pylorospasm,  which  usually  consist  of 
hyperacidity,  hypersecretion,  or  fissures  and  ulcers  in  the  region 
of  the  pyloric  exit.  This  treatment  may  be  dietetic  or  medicinal, 
or  it  may  consist  of  lavage  or  the  oil  cure  already  described  (see 
page  481).  Organic  stenosis  yields  with  much  greater  difficulty,  if 
at  all,  to  internal  medication. 

Einhorn  has  constructed  a  special  pyloric  dilator  (Fig.  82) 
which  is  useful  in  stenosis  of  the  pylorus  and  in  spasmodic  con- 
traction of  the  pylorus.  This  mode  of  treatment  will  probably 
find  application  in  specially  selected  cases,  principally  of  pyloro- 
spasm due  to  gastric  ulcer  or  to  remote  reflexes  (see  page  400). 
Benign  pyloric  strictures  can  also  be  widened  with  the  pyloric 
dilator.  The  results  from  this  method  of  treatment  are  very 
encouraging.  Internal  stretching  of  the  pylorus  should  be 
attempted  in  all  benign  cases  before  considering  surgical  inter- 
vention. Its  use  is  imperative  in  benign  pyloric  strictures  com- 
plicated with  affections  of  the  heart  or  kidneys  or  grave  lesions 
of  the  liver;  for  in  these  cases  the  mortality  of  operative  measures 
is  so  great  as  almost  to  forbid  it,  while  the  widening  of  the  pylorus 
by  the  internal  route  can  be  done  practically  without  danger.  A 
modification  of  the  pyloric  dilator  has  for  its  object  stretching  of 
the  pylorus  in  situ,  which  is  impossible  with  the  other  instruments. 
This  modified  dilator  is  provided  with  a  double-canal  tube  and 
two  balloons,  which  can  be  inflated  separately.     When  this  tube 


MOTOR  INSUFFICIENCY  OF  THE  SECOXD  DEGREE         185 


is  in  the  duodenum  the  end  balloon  is  inflated  and  pulled  up  to 
the  pylorus,  theE  allowed  to  recede  about  half  an  inch.  There- 
upon the  second  balloon,  collapsed,  and  lying  just  within  the 
pylorus,  is  inflated  and  left  in  position  for  about  one  minute.  This 
should  be  practiced  about  once  a  week.  The  technic  is  given  in 
detail  on  page  400. 

I  have  used  the  pyloric  dilator  with  remarkable  success  in  one 
case  of  benign  stenosis  of  the  pylorus.  The  patient  was  a  man 
forty-eight  years  of  age.  He  had  been  sick  nine  years.  For  the 
last  five  years  the  great  discomfort  he  experienced  compelled  him 
to  wash  out  his  stomach  frequently.  Pain,  and  sometimes  vomit- 
ing, would  come,  on  about  two  hours  after  meals.  At  times  he 
would  vomit  enormous  quantities  of  food  that  he  had  taken  days 
before.  He  had  lost  thirty  pounds  in  weight;  was  tired  quickly; 
had  backache  and  was  constipated.  His  stomach  contents  showed 
stagnation  with  hyperchlorhydria.  No  Oppler-Boas  bacilli  could 
be  found,  but  there  was  an  abundance  of  sarcinse.  The  feces  con- 
tained no  occult  blood.  The  use  of  the  pyloric  dilator  brought 
about  an  apparently  complete  recovery.  The  dilator  was  used 
only  three  times  during  twelve  days.  The  patient  improved  so 
rapidly  that  it  was  unnecessary  to  do  any  more  stretching  of  the 
pylorus.  He  regained  his  weight  and  strength.  It  is  now  over 
two  years  since  the  last  stretching. 


Fig.  82. — Einhorn  pyloric  dilator.    A,  rubber  bag  with  gauze  envelope,  collapsed. 
B,  rubber  bag  with  gauze  envelope  inflated  with  air;  C,  stopcock. 

Surgical  Treatment. — Should  internal  medication  combined  with 
the  treatment  outlined  fail  after  a  reasonable  time,  the  patient 
should  be  referred  to  the  surgeon.  Gastroenterostomy  is  usually 
followed  by  favorable  and  permanent  results  in  benign  stenosis  of 
the  pylorus.     For  the  treatment  of  carcinoma  see  Chapter  XXIX. 

Gastric  Tetany. — Kussmaul  was  the  first  to  draw  our  attention 
to  the  fact  that  in  certain  cases  of  dilatation  of  the  stomach  teta- 


486  MOTOR  INSUFFICIENCY 

noid  spasms  occur.  We  now  know  that  there  are  several  condi- 
tions of  the  gastro-intestinal  tract  which  may  cause  convulsive 
attacks.  Robson  and  Moynihan  believe  that  the  appropriate 
treatment  in  all  cases  of  gastric  tetany  is  surgical.  They  conclude 
that  in  almost  all  cases  there  is  a  mechanical  obstruction  to  the 
onward  passage  of  food.  It  is  this  stenosis  which  causes  dilatation 
and  hypertrophy  of  the  stomach.  To  relieve  the  obstruction  and 
to  prevent  stagnation  of  the  stomach  contents,  surgical  measures 
are  necessary. 

ACUTE  DILATATION  OF  THE  STOMACH. 

This  condition  is  noted  especially  after  laparotomies,  injuries, 
chloroform  narcosis,  torsion  of  the  duodenum  or  of  the  mesentery, 
dietetic  errors,  severe  infectious  diseases  such  as  pneumonia  and 
scarlet  fever,  and  chronic  exhausting  diseases  interfering  with  the 
internal  secretions.  It  is  assumed  by  some  that  dilatation  of  the 
stomach  follows  any  condition  that  causes  acidosis  of  the  stomach 
wall.  The  main  feature  is  the  immense  distention  of  the  stomach 
and  upper  part  of  the  duodenum.  The  dilated  portion  is  outlined 
abruptly  where  the  mesenteric  artery  crosses  and  compresses  the 
duodenum.  The  distended  stomach  exerts  traction  on  the  mesen- 
tery below  the  duodenum,  thus  tightening  the  pressure  on  the  latter 
and  starting  a  dangerous  vicious  circle.  The  swallowing  of  air  after 
operation  progressively  distends  the  stomach  and  frequently  causes 
a  condition  of  dilatation.  This  condition  is  evidently  the  first 
phase  of  an  "arteriomesenteric  occlusion  of  the  duodenum"  (see 
page  743) .  Aerophagy  is  occasionally  the  primary  factor  in  some  of 
these  surgical  and  medical  cases. 

When  acute  dilatation  of  the  stomach  takes  place  in  a  pre- 
viously healthy  person  the  clinical  symptoms  are,  as  a  rule,  most 
pronounced.  These  symptoms  consist  of  vomiting,  intermittent 
pains,  collapse,  feeble  pulse,  accelerated  respiration,  and  constipa- 
tion. When  the  condition  does  not  readily  clear  up,  it  must 
always  be  regarded  as  very  grave. 

Intestinal  obstruction  invariably  causes,  as  one  of  its  early 
symptoms,  dilatation  of  the  stomach  (see  page  745). 

Treatment. — When  a  diagnosis  of  acute  dilatation  has  been 
made,  the  stomach  should  be  emptied  and  lavage  performed  as 
frequently  as  indicated.  No  food  should  be  given  by  mouth; 
the  nourishment  should  consist  of  nutritive  enemata.  Otherwise 
treatment  should  be  directed  to  the  reestablishment  of  normal 
gastric  peristalsis.  Rectal  enemata  (proctoclysis)  consisting  of 
large  quantities  of  physiologic  salt  solution  are  indicated.  In 
selected  cases  strychnin  sulphate  and  atropin  should  be  employed. 
Collapse  should  be  treated  by  means  of  stimulants  and  normal 
salt  solution. 


ACUTE  DILATATION  OF  THE  STOMACH  487 

Early,  prolonged  and  repeated  lavage  reestablishes  the  normal 
mechanism  of  digestion.  It  relieves  the  stomach  and  duodenum 
of  uras,  stagnated  fluid,  and  the  residues  of  secretion.  The  removal 
of  this  toxic  material  is  conducive  to  recovery,  since  the  stomach 
then  contracts,  thus  relieving  the  arteriomesenteric  pressure.  It 
may  be  necessary  to  continue  this  process  for  many  hours.  Cathar- 
tics are  absolutely  contra-indicated.  When  the  trouble  is  due  to 
abnormal  fermentations  or  overloading,  the  washing-out  of  the 
stomach  has  a  direct  curative  action,  and  even  when  the  trouble 
is  of  other  origin  it  has  a  very  useful  palliative  effect.  The  patient 
may  be  placed  in  the  Trendelenburg  position,  a  stomach  tube 
being  used  for  drainage.  Epinephrin  is  especially  indicated  when 
there  is  reason  to  assume  that  the  severe  symptoms  are  the  result 
of  acute  exhaustion  of  adrenal  function.  Patients  should  always 
lie  on  the  right  side  to  assist  in  emptying  the  stomach  contents 
through  the  pylorus.  When  these  measures  fail,  gastroenteros- 
tomv  is  indicated. 


CHAPTER  XXV. 

GASTRIC  ULCER. 

Ulcus  Ventriculi — Round  Ulcer — Peptic  Ulcer — Perforating 

Gastric  Ulcer. 

Gastric  ulcer  is  a  localized  lesion  of  the  mucous  membrane 
of  the  stomach.  It  is  characterized  by  a  sharp,  well-defined  out- 
line, more  or  less  deep  destruction  of  the  mucosa,  and  by  no  ten- 
dency to  heal.  The  lesion  gives  rise  to  one  or  more  characteristic 
symptoms — pain,  vomiting,  hematemesis.  Gastric  ulcer  was  first 
described  by  Cruveilhier  in  1829. 

Pathology. — Gastric  ulcer  is  usually  round  or  oval  in  shape. 
In  some  instances  several  ulcers  may  become  confluent  and  thus 
form  a  larger  one  with  an  irregular  border.  Owing  to  the  ten- 
dency of  the  ulcer,  which  is  at  first  superficial  (florid  ulcer),  to 
penetrate  deeply,  the  base  is  frequently  the  muscular  or  serous 
coat  of  the  stomach.  In  "perforating  ulcer"  the  base  is  one  of 
the  adjacent  viscera,  bound  to  the  stomach  by  adhesions.  The 
ulcer  is  funnel-shaped,  with  the  base  as  the  apex.  As  a  rule  ulcers 
do  not  attain  a  size  much  larger  than  a  dime,  though  some  of  the 
confluent  variety  have  measured  ten  centimeters  (over  three  inches) 
in  their  greatest  diameter.  An  ulcer  the  size  of  a  pea  may  exhibit 
all  the  characteristic  symptoms  of  this  pathologic  condition.  The 
typical  gastric  ulcer  has  a  punched-out  appearance. 

Chronic  ulcer  consists  of  excavations  in  the  gastric  wall  having 
either  the  mucosa,  musculature,  serosa  or  perigastric  structures  as 
their  base.  The  mucosa  may  recede  or  overhang  the  base,  which 
consists  of  scar  tissue,  radiating  from  the  center.  All  chronic 
ulcers  are  protected  with  a  callus  which  forms  the  base  of  the  ulcer. 
In  carcinomatous  degeneration  the  carcinomatous  cells  are  usually 
found  in  the  overhanging  mucosa. 

On  microscopic  section  of  recent  ulcers  the  margins  show  the 
ducts  of  the  gastric  glands  cut  off  toward  the  base  of  the  ulcer. 
In  chronic  ulcers,  owing  to  a  reactive  inflammation  at  the  per- 
iphery, a  thickening  of  connective  tissue  is  formed  there  (callous 
ulcer)  which  may  be  palpated — especially  if  the  ulcer  is  located 
near  the  pylorus.  Apart  from  the  inflammation  surrounding  the 
edges  of  the  ulcer,  the  remainder  of  the  gastric  mucosa  is  likely  to 
be  normal. 

In  the  acute  form  of  the  lesion  the  necrotic  process  may  be  so 


SEX  PREDISPOSITION  AND  AGE  489 

rapid  that  the  thin  serous  coat  is  perforated  (perforating  ulcer), 
or  a  vessel  may  be  so  eroded  as  to  occasion  severe  hemorrhage, 
with  a  fatal  termination. 

Etiology. — The  lesser  curvature  seems  to  be  the  favorite  seat 
of  ulceration.  In  about  86  per  cent,  of  cases  the  ulcer  is  situated 
on  the  posterior  surface  of  the  lesser  curvature  and  at  the  pyloric 
sac — parts  of  the  stomach  which  together  form  a  segment  of  less 
than  half  the  total  surface  of  the  viscus.  This  portion  of  the 
stomach  is  subjected  to  the  greatest  irritation  from  the  moving 
mass  of  gastric  contents  before  the  latter  are  entirely  reduced  to 
liquid  form.  Another  explanation  is  that  these  parts  of  the  gastric 
mucosa  may  be  insufficiently  nourished,  in  consequence  of  dis- 
turbances of  circulation  due  to  spastic  contraction  (vagotonia, 
see  page  388),  so  that  they  are  attacked  by  the  digestive  activity 
of  the  normal  gastric  juice,  and  the  so-called  peptic  ulcer  is  the 
result.  Such  disturbances  in  circulation  may  also  be  caused  by 
severe  trauma,  simple  injury  to  the  stomach,  or  traumatic  influ- 
ences extending  over  a  prolonged  period,  such  as  pressure  from 
corsets,  the  wearing  of  belts  by  workingmen,  continuous  work 
in  a  bent  position,  or  the  tasting  of  superheated  dishes  by  cooks. 
Insufficient  nourishment,  induced  by  circulatory  disturbances,  is 
also  traceable  to  embolism  or  thrombosis  of  the  small  arteries 
supplying  the  lesser  curvature  of  the  stomach;  specific  endar- 
teritis; venous  stagnation, '  from  chronic  inflammatory  processes 
of  the  mucous  membrane;  and  altered  composition  of  the  blood 
(anemia,  chlorosis).  A  focus  of  infection  (oral  sepsis)  may  be  the 
predominating  factor  in  the  causation  of  gastric  ulcer  (see  Duo- 
denal Ulcer,  Chapter  XLI).  From  typical  indurated  ulcers  of  the 
stomach,  streptococci  have  been  isolated,  suggesting  a  bacterial 
origin  for  the  ulceration;  and  these  same  streptococci  (viridans) 
injected  intravenously  in  animals  have  caused  ulcerations  of  the 
stomach.  Autodigestion  never  occurs  in  the  gastro-intestinal 
tract  below  the  field  of  action  of  the  peptic  ferment.  There  are 
no  "tryptic  ulcers,"  like  the  "peptic  ulcers."  This  is  explained 
by  the  ability  of  the  peptic  ferment  to  digest  raw  connective  tissue, 
which  the  tryptic  ferment  is  unable  to  do  (see  page  119).  The  initial 
lesion  of  peptic  ulcer  may  also  be  due  to  a  derangement  of  the 
internal  secretions  (see  page  388). 

Frequency. — Lebert  found  one  case  of  gastric  ulcer  in  200  autop- 
sies. Griinfeld  places  the  number  at  20  per  cent.  These  are  the 
extremes.  Brinton  found  5  cases  in  100  autopsies;  Berthold,  one 
in  every  37,  or  in  that  proportion.  In  a  clinical  study  of  1000 
cases  of  gastric  disturbances  of  various  kinds,  Friedenwald  found 
that  7.8  per  cent,  were  affected  with  ulcer  of  the  stomach  or  duo- 
denum. 

Sex  Predisposition  and  Age. — Gastric  and  duodenal  ulcers  occur 
much  more  frequently  in  males  than   in  females.     Of   chronic 


490  GASTRIC  ULCER 

gastric  ulcer  coming  to  operation.  Mayo  reports  29  per  cent,  females 
and  71  per  cent,  males.  These  ulcers  have  been  observed  at  an 
early  age,  Lees  having  found  perforation  of  the  stomach  in  children 
aged  eight  and  nine  years.  Habershon,  in  an  analysis  of  201  cases, 
noted  the  earliest  age  at  which  gastric  ulcer  occurred  to  be  ten 
years  (the  patient  a  girl);  several  children  (girls)  suffered  from 
gastric  hemorrhage  at  fourteen,  others  at  fifteen  and  sixteen;  the 
oldest  patient  was  a  man  aged  seventy-one.  This  writer  found 
the  disease  to  be  most  frequent  in  the  period  between  twenty  and 
fifty  years.  In  women  the  period  of  liability  was  noted  to  begin 
earlier  than  in  men,  and  to  reach  its  maximum  at  twenty-five  to 
thirty.     In  men  the  earliest  case  occurred  at  the  age  of  twenty. 

Effect  of  Healing. — Deep  ulcer  heals  by  cicatrization.  The  scar 
is  pale  and  star-shaped,  with  a  puckering  of  the  surrounding  mucous 
membrane.  Cicatrization  and  scarring  may  eventually  lead  to 
deformity  of  the  stomach,  producing  the  so-called  hour-glass  con- 
traction. Hour-glass  stomach  is  readily  diagnosticated  by  means 
of  the  Roentgen  ray  (see  Plate  XV,  Fig.  2).  More  often,  how- 
ever, there  is  interference  with  gastric  movement  and  function  by 
adhesions  to  neighboring  organs.  Stenosis  of  the  pylorus,  with 
resultant  obstruction  and  dilatation  of  the  stomach,  occurs  in  the 
healing  of  ulcers  near  the  pyloric  exit.  The  involvement  of  the 
pneumogastric  nerve  in  the  scar  occasionally  gives  rise  to  intense 
suffering. 

Symptoms. — The  symptoms  of  gastric  ulcer  are  at  first  ill-defined, 
resembling  those  of  gastritis;  much  will  depend  upon  the  size, 
shape,  depth  and  location  of  the  ulcer.  There  is  more  or  less 
discomfort  after  partaking  of  food;  and  later  on  in  the  course  of 
the  disease  nausea  may  develop,  or  more  often  regurgitation  of 
food,  or  vomiting.  A  periodic  boring  pain  is  characteristic  of  well- 
established  gastric  ulcer;  it  comes  on  always  within  an  hour  after 
eating,  sometimes  as  soon  as  the  food  is  ingested,  and  may  be 
aggravated  by  the  character  of  the  latter,  especially  when  not  well 
masticated.  Fruits  and  vegetables  favor  the  development  of  the 
gastric  pain,  whereas  proteins  may  relieve  it.  (The  pain  in  duo- 
denal ulcer  appears  at  any  time  from  two  to  three  hours  after 
eating,  and  is  relieved  by  the  taking  of  food.)  Liquid  food  is 
borne  much  better  than  solid.  Pain  in  these  conditions  varies  in 
intensity  from  the  slightest  pressure  discomfort  to  paroxysmal 
agony.  The  painful  seizures  are  particularly  frequent  and  severe 
in  gastric  ulcer  complicated  with  hypersecretion,  hyperacidity,  and 
pylorospasm  (see  page  398).  The  appetite  is  usually  good,  but, 
since  eating  is  followed  by  such  distressing  symptoms,  patients 
are  inclined  to  eat  as  little  as  possible  and  consequently  they 
become  much  emaciated  as  the  condition  progresses. 

It  is  now  established  that  the  sensation  of  hunger  is  induced 
by  a  type  of  tonic  and  peristaltic  contractions  of  the  empty  or 


SYMPTOMS  491 

nearly  empty  stomach.  These  gastric  hunger  contractions  occur 
with  a  rhythm  and  intensity  that  have  no  relation  to  the  peculiar 
character  of  the  food  ingested.  The  tension  of  excessive  contrac- 
tions on  sensory  nerves  rendered  hyperexcitable  by  the  presence 
of  gastric  ulcer  will  result  in  more  or  less  severe  pain;  and  there 
is  evidence  that  the  pains  of  gastric  and  duodenal  ulcers  are  con- 
traction pains  arising  in  the  stomach,  pylorus,  or  duodenum.  They 
have  been  correctly  named  hunger  pains.  These  pains  are  tem- 
porarily relieved  by  any  measure  which  inhibits  or  decreases 
gastric  tonus.  This  result  can  be  brought  about  by  the  ingestion 
of  food,  alkalis,  or  water. 

Localization  of  Pain. — The  location  of  the  pain  corresponds,  as 
a  rule,  to  the  center  of  the  epigastrium — at  the  median  line,  just 
below  the  ensiform  cartilage.  The  portion  of  the  epigastric  region 
to  which  the  pain  is  referred  forms  a  circular  area  of  less  than  two 
inches  in  diameter.     The  pain  is  increased  on  pressure. 

Cruveilhier  first  described  the  dorsal  pain,  which  appears  a  few 
weeks  or  months  later  than  the  epigastric  pain.  This  pain,  which 
is  of  a  gnawing  character,  is  to  the  left  of  the  spine  and  at  about 
the  eighth  or  ninth  dorsal  vertebra.  It  may  extend  occasionally 
to  the  first  or  second  lumbar  vertebra.  Boas  has  drawn  atten- 
tion to  a  dorsal  point  of  pressure  at  the  level  of  the  tenth  to  the 
twelfth  dorsal  vertebra,  with  a  lateral  extension  of  two  or  three 
centimeters  and  a  height  of  one  to  four  centimeters.  This  pressure 
point  is  usually  left  of  the  median  line. 

Vomiting. — Vomiting  usually  occurs  an  hour  or  two  after  meals, 
or  when  the  pain  is  at  its  height;  and  the  pain  is,  as  a  rule,  relieved 
by  the  emesis.  The  vomitus  consists  of  either  gastric  juice  or 
watery  fluid  containing  partially  digested  food  remnants.  Instead 
of  vomiting,  the  patient  may  have  attacks  of  nausea. 

Hemorrhage. — Hemorrhage,  if  slight,  may  pass  unnoticed;  but 
if  there  is  any  considerable  quantity  of  blood  in  the  vomitus  it 
will  impart  to  the  latter  a  red  or  coffee-brown  appearance.  When 
it  is  not  possible  to  detect  the  presence  of  blood  from  the  macro- 
scopic appearance  of  the  vomitus  or  dejecta,  it  is  well,  in  suspicious 
cases,  to  resort  to  Weber's  test  (see  page  86)  for  occult  blood. 
The  examination  of  both  gastric  contents  and  feces  by  means  of 
this  test  to  detect  concealed  hemorrhages  is  of  great  assistance. 
The  benzidin  test  and,  more  recently,  the  phenolphthalein  test 
have  been  devised,  which  give  more  characteristic  reactions  (see 
pages  123  and  124). 

When  gastric  hemorrhage  is  profuse,  the  patient  will  experience 
a  feeling  of  giddiness,  weakness,  syncope,  and  extreme  thirst. 
Among  the  objective  symptoms  is  pallor,  the  degree  of  which  will 
depend  upon  the  amount  of  blood  lost.  If  the  effusion  of  blood  in 
the  stomach  is  considerable,  hematemesis  or  melena  may  occur. 
Hematemesis  as  a  symptom  is  not  necessary  to  the  diagnosis  of 


492  GASTRIC  ULCER 

gastric  ulcer,  though  it  aids  in  confirming  the  diagnosis.  It  occurs 
in  about  half  the  cases. 

Perforation. — Perforation  is  one  of  the  most  frequent  causes  of 
death  from  gastric  ulcer.  The  extravasation  of  gastric  contents 
into  the  peritoneal  cavity  is  attended  by  sudden  and  severe  abdomi- 
nal pain  similar  to  that  brought  on  by  exertion  or  by  some  dietetic 
error.  Syncope  and  collapse,  weak,  running  pulse,  and  peritonitis 
with  a  fatal  termination,  is  the  usual  result  of  perforation  of  a  full 
stomach.  Disappearance  of  hepatic  dulness  is  of  notable  diagnostic 
value.  An  early  sign  of  perforation  of  the  stomach  is  tenderness 
of  the  pouch  of  Douglas.  The  stomach  contents  frequently  flow 
down  and  accumulate  here,  which  explains  the  extreme  tenderness 
at  this  point.  (If  the  stomach  be  empty,  the  symptoms  of  per- 
foration are  comparatively  unimportant.)  In  the  event  of  extra- 
vasation of  gastric  contents  into  the  peritoneal  cavity,  life  is  saved 
only  by  prompt  resort  to  operative  intervention.  In  operations 
performed  within  ten  hours  after  perforation  the  mortality  is  28 
per  cent.;  if  the  operation  be  delayed  for  more  than  twenty-four 
hours  the  mortality  rises  to  65  per  cent. ;  after  thirty-six  hours,  to 
87  per  cent.  Later,  operation  is  practically  hopeless.  (See  Plate 
XIV,  Figs.  3  and  4,  and  Plate  XV,  Fig.  1.) 

In  perforations  in  which  diffuse  infection  does  not  take  place, 
owing  to  the  fact  that  there  was  no  food  in  the  stomach,  adhesions 
are  formed  with  neighboring  viscera.  This  subject  is  discussed 
under  the  heading  Perigastritis,  Chapter  XXVII. 

Willan  draws  attention  to  the  presence  of  a  ring  of  constriction 
across  the  abdomen  at  the  level  of  the  lower  margins  of  the  ribs 
as  a  helpful  diagnostic  sign  in  cases  of  perforated  gastric  ulcer. 
The  appearance  is  as  if  the  abdomen  were  constricted  above  the 
level  of  the  umbilicus  and  below  the  transpyloric  plane  by  an 
invisible  rope,  which  represents  the  level  of  the  lowermost  limits 
of  the  costal  arch  and  may  be  termed  the  "infracostal"  line.  The 
constriction  does  not  disappear  with  general  anesthesia,  but  does 
disappear  when  that  condition  has  advanced  to  the  stage  of  general 
abdominal  distention.  There  is  no  marked  hyperesthesia,  and 
the  patient  has  no  feeling  of  tightness  at  the  site  of  the  constric- 
tion. It  is  assumed  that  the  powerful  impulses  resulting  from 
the  perforation  are  conveyed  by  the  sympathetic  fibers  to  the 
celiac  plexus  and  from  there  to  the  spinal  cord,  whence  the  whole 
nervous  system  is  probably  involved. 

Appetite. — The  appetite  is  apparently  not  affected  by  the  pres- 
ence of  gastric  ulcer,  though  patients  are  apt  to  eat  but  sparingly 
through  fear  of  the  pain  which  the  act  induces.  Patients  complain 
of  constant  hunger,  owing  to  this  inability  to  satisfy  the  appetite 
on  account  of  the  excessive  quantity  of  hydrochloric  acid  present. 
This  acidity  is  best  estimated  by  an  analysis  of  the  stomach  con- 
tents (see  page  67). 


DIAGNOSIS  493 

Complications  and  Sequela.— Manges,  from  the  viewpoint  of 
origin,  classifies  the  complications  and  sequelae  of  gastric  ulcer  as 
(1)  intragastric;  (2)  extragastric.  Among  the  intragastric  are:  (a) 
hemorrhage;  (b)  profound  anemia;  (c)  interference  with  motility 
of  the  stomach  (if  the  lesion  extends  deeply  into  the  museularis); 
(d)  stenosis  of  the  cardia,  pylorus,  body  of  the  stomach  (hour- 
glass contraction);  (e)  gastrorrhea,  with  its  various  complications, 
such  as  tetany;  (J)  carcinoma.  The  extragastric  complications 
include:  (a)  perforation,  free  and  with  adhesions,  possibly  suppu- 
ration, also  subphrenic  and  other  abscesses,  fistulas  of  various 
kinds;  (6)  general  emphysema;  (c)  perigastritis,  with  localized 
thickening  of  the  serosa,  adhesions  to  various  organs,  displace- 
ment or  distortion  of  the  stomach.  These  sequelae  are  dealt  with 
in  this  and  other  chapters. 

Diagnosis. — A  probable  diagnosis  of  gastric  ulcer  may  be  made 
from  the  fact  of  profuse  hematemesis,  if  carcinoma  of  the  stomach 
and  obstruction  to  the  portal  circulation  can  be  excluded.  In 
every  case,  unless  the  ulcer  is  cicatrized,  occult  blood  is  demon- 
strable in  the  feces.  Pain  appearing  shortly  after  eating  and 
lasting  for  two  or  three  hours  is  of  diagnostic  import,  especially 
if  there  is  a  circumscribed  spot  in  the  epigastric  region  that  is 
painful  to  pressure,  or  a  similar  sensitive  area  to  the  left  of  the 
eighth  or  ninth  dorsal  vertebra.  Vomiting  occurring  shortly  after 
meals  in  patients  who  have  recently  become  pale  and  anemic  will 
justify  a  probable  diagnosis  of  gastric  ulcer.  Should  the  vomiting 
culminate  in  hematemesis  or  melena,  and  cause  a  cessation  of  pain, 
the  physician  may  reasonably  conclude  that  the  lesion  is  gastric 
ulcer.  The  relief  of  pain  afforded  by  orthoform  is  of  diagnostic 
value  (see  page  270). 

The  development  of  chronic  gastric  ulcer  is  frequently  due  to 
vagotonia,  or  increased  irritability  of  the  vagus  (see  page  388;. 

For  determining  the  presence  and  location  of  gastric  or  duodenal 
ulcer,  the  "string  test"  devised  by  Einhorn  has  been  found  valu- 
able (Figs.  83  and  84).  The  stomach  being  empty,  the  patient 
swallows,  preferably  at  night,  the  Einhorn  duodenal  bucket 
attached  to  a  braided  silk  string  85  centimeters  long,  which  is  to  be 
knotted  just  before  removal  at  the  level  of  the  upper  incisor  teeth. 
A  loop  at  the  upper  end  of  the  string  is  placed  over  the  ear  to  pre- 
vent the  upper  part  of  the  string  from  passing  into  the  stomach. 
The  bucket  is  withdrawn  on  the  following  morning  and  the  string 
examined  for  a  red  or  brown  stain.  The  lower  end  of  it  is  found 
to  be  yellow  or  greenish-yellow,  and  the  bucket  contains  bile  mixed 
with  mucus,  provided  it  has  passed  the  pylorus — which  it  invari- 
ably does  in  from  two  to  eight  hours  if  there  is  no  obstruction  at 
the  pylorus.  Should  the  bucket  fail  to  pass  into  the  duodenum,  a 
smaller  one  is  used  the  succeeding  night,  and  in  this  manner  an 
approximate  idea  of  the  caliber  of  the  pylorus  may  be  gained. 


494 


GASTRIC  ULCER 


By  measuring  the  distance  from  the  knot  in  the  string  to  the  red 
or  brown  stain  (should  there  be  one),  we  are  able  to  definitely 
localize  the  ulcer.  If  the  stain  is  39  to  42  centimeters  from  the 
incisor  teeth,  the  ulcer  is  located  at  the  cardia;  if  44  to  54  centi- 
meters, at  the  lesser  curvature;  if  55  to  56  centimeters,  at  the 
pylorus;  and  if  over  57  centimeters,  in  the  duodenum.  I  have 
substituted  a  large  porcelain  bead  for  the  Einhorn  bucket  and  find 
that  it  serves  equally  well.  If  this  test  be  made  several  times 
on  one  individual,  and  each  time  a  red  or  brown  stain  is  found  at 
about  the  same  distance  from  the  teeth,  the  clinician  may  be 
sure  that  a  localized  lesion  of  the  gastric  mucosa  exists,  which  is 
probably  ulcer.     This  test  gains  in  value  the  more  I  use  it. 


Fig.  83. — A  negative  string. 


Fig.  84. — A   positive   string. 


Roentgenography  is  of  great  assistance  in  the  diagnosis  and 
location  of  chronic  gastric  ulcer.  In  the  superficial  or  florid  cases 
it  does  not  help  as  much.  In  all  cases  of  the  callous  type  roent- 
genologic diagnosis  usually  proves  correct,  as  shown  by  operation 
(see  page  141). 

Prognosis.— With  a  better  understanding  of  the  etiology  and 
pathology  of  gastric  ulcer,  as  well  as  improved  methods  of  treat- 
ment, the  outlook  for  complete  recovery  is  much  more  favorable 
than  formerly.  The  reason  there  are  not  more  successes  in  the 
treatment  of  this  pathologic  condition  is  that  patients  frequently 
present  such  indefinite  symptoms  that  the  nature  of  the  disease 
is  obscured  and  improper  treatment  instituted.  The  further  fact 
that  physicians  too  often  fail  to  insist  upon  the  discipline  necessary 
for  the  accomplishment  of  the  best  results,  but  content  them- 
selves with  prescribing  a  few  dietary  rules  and  some  harmless 
drug,  has  resulted  in  a  chronicity  that  at  times  resists  rational 


TREATMENT  195 

treatment.  The  physician  should  insist  very  strongly  on  the  rest 
cure.  The  older  the  ulcer  the  more  unfavorable  the  prognosis. 
Peptic  ulcer  having  its  base  on  the  serous  membrane  or  on  some 
organ  in  close  proximity  to  the  stomach  will  resist  all  medical  treat- 
ment; surgery  is  the  only  recourse  in  such  cases  (callous  ulcer). 
The  location  of  the  ulcer  is  a  matter  of  importance:  in  ulcers  of 
the  pylorus,  owing  to  the  fact  that  they  tend  to  produce  cicatricial 
stenosis,  sometimes  the  only  hope  of  recovery  lies  in  operative 
treatment.  When  the  ulcers  are  deep  we  are  apt  to  have  such 
complications  as  hemorrhage  from  perforation,  adhesions  to  the 
spleen  if  the  ulcer  happens  to  be  located  in  the  fundus,  and  peri- 
gastritis. With  hypersecretion  as  an  accompaniment  the  prognosis 
of  gastric  ulcer  is  less  favorable  than  when  there  is  simple  hyper- 
acidity (see  page  97) . 

Treatment. — Prophylaxis. — Hygiene  of  the  mouth  is  most  impor- 
tant (see  page  296).  A  properly  selected  diet  will  do  much  to  pre- 
vent the  occurrence  of  ulcer  of  the  stomach.  An  absolute  milk 
diet  should  be  prescribed  as  soon  as  the  first  symptoms  of  the 
disease  become  manifest.  Care  should  be  exercised  to  avoid 
extremes  of  temperature  in  food.  An  effort  should  be  made  to 
overcome  the  hyperchlorhydria  which  is  an  important  etiologic 
factor  in  gastric  ulcer.  The  anemia  which  is  a  frequent  accom- 
paniment of  the  disease  should  likewise  be  treated. 

Leube-Ziemssen  Treatment. — A  therapeutic  procedure  suitable  to 
slight  or  moderately  severe  cases  of  gastric  ulcer  uncomplicated 
by  hemorrhage  is  the  Leube-Ziemssen  treatment.  After  the  diag- 
nosis has  been  confirmed,  the  patient  is  given,  for  the  first  four- 
teen days,  complete  rest  in  bed.  Even-  morning,  an  hour  before 
partaking  of  food,  he  is  given  one-quarter  liter  (§  pint)  of  Carlsbad 
Muhlbrunnen  water  (at  90°  F.)  in  which  is  dissolved  5  to  10  Gm. 
(75  to  150  grains)  of  natural  or  artificial  Carlsbad  salts.  It  is  also 
advisable  to  dissolve  10  grams  of  Carlsbad  salts  in  a  quarter  of 
a  liter  of  pure  water  at  a  temperature  of  90°  F.,  to  be  sipped  at 
intervals. 

Hot  fomentations  are  applied  over  the  epigastrium  during  the 
day.  For  this  purpose  mashed  potato  poultices  or  linseed  poul- 
tices are  good.  A  piece  of  clean  flannel  cloth  should  be  interposed 
between  the  skin  and  the  poultice.  In  using  thermophores  or 
electric  heating  pads,  which  furnish  a  continuous  even  temperature, 
care  should  be  exercised  to  avoid  pressure  on  the  stomach.  During 
-the  night  a  moist  Priessnitz  bandage  may  be  allowed  to  remain  in 
place  (see  page  250). 

The  diet  for  the  first  ten  to  fourteen  days  consists  chiefly  of  milk, 
neither  hot  nor  cold.  During  the  first  two  or  three  days  of  the 
fourteen,  a  quarter  of  a  liter  (£  pint)  of  milk  is  given  per  day,  in 
tablespoonful  doses  at  regular  intervals.  This  quantity  is  then 
gradually  increased  to  one-half  liter,  and  at  the  end  of  the  first 


496  GASTRIC  ULCER 

week's  treatment  to  one  liter.  The  caloric  value  of  this  small 
quantity  of  milk  may  be  enhanced  by  the  addition  of  cream;  the 
increase  in  caloric  value  can  be  estimated  from  the  following 
calculation  by  Strauss: 

Calories. 

A     100  Gm.  full  milk .         70 

B       75  Gm.  full  milk  +  25  Gm.  cream 115 

C       50  Gm.  full  milk  +  50  Gm.  cream 185 

D       25  Gm.  full  milk  +  75  Gm.  cream 205 

E     100  Gm.  cream 250 

Therefore  there  are  present  in  one-half  liter  (1  pint)  of  each  of 
these — milk,  milk  and  cream,  and  cream — the  following: 

Calories. 

A 350 

B         575 

C         925 

D         1025 

E .     1250 

Yolk  of  egg  may  be  added  to  the  milk.  When  milk  is  ill-borne 
or  patients  exhibit  a  dislike  for  it,  it  may  be  made  more  palatable 
by  the  addition  of  tea,  cocoa,  vanilla,  or  milk  rice  and  milk  jellies. 
Beaten  cream  or  cream  jellies  may  be  given.  Milk  soups  with 
rice,  oatmeal,  or  the  infant  flours  (half  a  tablespoonful  of  flour  to 
half  a  pint  of  milk)  will  be  found  agreeable  to  most  patients.  Sugar 
may  be  added  to  suit  the  taste. 

When  aversion  to  milk  is  very  pronounced,  do  not  insist  on 
its  use.  In  such  cases  the  most  suitable  substitute  during  the  first 
days  of  treatment  is  yolk  of  egg  beaten  up  with  sugar  so  that 
the  patient  takes  two  to  four  eggs  per  day;  or  flour  soups  with  the 
addition  of  butter  may  be  given  instead. 

When  the  quantity  of  food  taken  is  too  small,  on  account  of 
severe  pain,  it  is  advisable  to  add  to  the  soups  such  concentrated 
foods  as  plasmon  or  fluid  somatose.  Jellies  made  from  chicken, 
meat  or  raspberries  may  be  employed  with  advantage.  Patients 
who  are  fond  of  sweets  should  be  given  syrupy  fruit  juices,  such 
as  are  made  from  apples  or  raspberries;  or  malt  extract  may  be 
added  to  the  milk  or  cocoa. 

This  strict  diet,  as  outlined,  is  continued  for  at  least  ten  days. 
If  the  pains  subside  rapidly  the  diet  may  be  increased.  When, 
however,  the  pain  persists,  it  is  necessary  to  prolong  the  period 
of  physiologic  rest  to  fourteen  days. 

As  might  be  expected,  patients  on  such  a  regimen  decrease  in 
weight.  The  loss  of  weight,  however,  may  be  accepted  calmly, 
since  the  meager  diet  has  contributed  to  the  comfort  of  the  patient 
and  shielded  the  gastric  mucosa  from  undue  irritation. 

Near  the  end  of  the  second  week,  if  the  patient's  condition  per- 
mits, bouillon  or  soups  enriched  with  yolk  of  egg,  breast  of  chicken, 
or  squab,  enter  into  the  dietary.     The  flour  soups  mentioned  may 


TREATMENT  497 

be  continued.  When  the  pains  have  wholly  disappeared  a  careful 
trial  may  be  made  of  a  few  teaspoonfuls  of  very  finely  chopped 
breast  of  chicken  or  squab.  If  this  is  easily  borne,  light  egg  dishes 
are  added  to  the  dietary.  Then,  tentatively,  a  few  dessertspoon- 
fuls of  mashed  potatoes,  softened  biscuits  (crackers)  or  zwieback 
may  be  administered.  Owing  to  the  preponderance  of  liquid 
nourishment,  patients  do  not  experience  much  thirst  during  the 
first  and  second  periods  of  the  treatment;  thirst  may  be  allayed 
by  small  pieces  of  ice  dissolved  in  the  mouth.  The  white  of  an 
egg  mixed  with  200  Cc.  (§  vij)  of  water  sweetened  with  a  teaspoonful 
of  sugar  is  recommended  as  a  beverage. 

The  diet  during  the  second  period  (beginning  with  the  fifteenth 
day  of  the  treatment)  is  maintained  until  the  end  of  the  third  week, 
during  which  time  the  patient  is  kept  at  rest  in  bed.  Carlsbad 
water  is  continued,  likewise  the  hot  applications  over  the  epigas- 
trium. At  the  end  of  three  weeks  the  patient  may  be  placed  upon 
a  more  extended  diet;  such  articles  of  food  as  light  cheese,  boiled 
chicken,  squab,  small  steak,  sweetbreads,  and  minced  veal  cutlets, 
are  permitted.  Ham  and  uncooked  meat  must  be  avoided.  At 
this  period  of  the  treatment  fish,  such  as  pike  or  trout,  well  cooked 
and  served  with  butter  balls  and  butter  sauce,  may  be  introduced; 
also  mashed  potatoes,  as  well  as  other  kinds  of  vegetables  in  the 
form  of  purees.  The  quantity  of  biscuits  and  zwieback  may  be 
increased,  care  being  exercised  that  such  articles  are  completely 
broken  up  and  taken  in  a  soft,  moist  condition.  The  milk  diet  is 
meanwhile  continued. 

The  hot  fomentations  need  not  be  resorted  to  so  frequently 
during  the  fourth  week.  During  the  latter  part  of  this  period  the 
patient  is  allowed  to  remain  out  of  bed  and  the  hot  applications 
are  discontinued  altogether.  The  diet  is  arranged  on  an  increas- 
ingly liberal  basis.  Such  foods  as  biscuits,  zwieback  and  white 
bread  toast  must  be  carefully  masticated.  The  regular  diet  to 
which  the  patient  has  been  accustomed  is  not  to  be  resumed  under 
two  months  from  the  initiation  of  the  treatment. 

Summary  of  Leube-Ziemssen  Treatment. — There  are  four  cardinal 
points  to  be  observed: 

1.  Rest  in  bed  for  one  or  two  weeks.  This  relieves  the  pain  and 
promotes  healing.  After  the  tenth  day  the  patients  lie  down  two 
hours  after  dinner. 

2.  Carlsbad  water,  a  quarter-liter  (f-  pint),  lukewarm,  every 
morning  for  two  weeks. 

3.  Application  of  a  hot  poultice  or  thermophore  to  the  epigas- 
trium. The  poultice  must  be  changed  every  fifteen  minutes  and 
kept  very  hot.  Leube  never  uses  poultices  in  the  treatment  of 
bleeding  ulcers,  as  they  are  apt  to  cause  a  recurrence  of  the  hemor- 
rhage.    During  hemorrhage  ice-bags  are  used  instead. 

4.  Light  diet  of  high  nutritive  value  and  ready  digestibility. 
32 


498  GASTRIC  ULCER 

Confining  the  patient  to  bed,  with  rectal  alimentation  (see  page 
243),  for  several  days  before  beginning  the  Leube  treatment,  is 
helpful.  The  reasonableness  of  this  procedure  is  apparent,  since 
absolute  rest  brings  about  a  cessation  of  pain  and  vomiting  and 
facilitates  the  healing  of  the  ulcer.  Persons  subject  to  ulcer  should 
lead  abstemious  lives  in  regard  to  diet  and  beverages,  and  those 
who  have  been  cured  should  not  undertake  heavy  work  or  violent 
exercise  within  a  year  from  the  cessation  of  the  symptoms. 

Lenhartz  Treatment. — Among  the  more  recent  methods  of  treat- 
ment of  gastric  ulcer,  especially  when  complicated  with  hemorrhage, 
is  that  devised  by  Lenhartz.  The  principle  underlying  this  treat- 
ment involves  the  maintenance  of  enforced  nutrition  from  the 
beginning — that  is,  from  the  time  of  the  hemorrhage.  Lenhartz 
administers  the  minimum  quantity  of  food  with  maximum  caloric 
value.  He  argues  that  in  the  Leube  treatment  the  nutrition  of  the 
patient  is  so  far  below  his  needs  that  the  anemic  condition  is  bound 
to  become  more  pronounced  and  the  chances  for  the  ulcer  to  heal 
are  greatly  lessened.  Lenhartz  by  his  protein  regimen  aims  to 
counteract  the  hyperacidity  so  frequently  present  in  gastric  ulcer. 
Strong  emphasis  is  placed  upon  the  importance  of  physical  rather 
than  physiologic  rest  of  the  stomach. 

The  Lenhartz  method  of  treatment  is  as  follows:  Absolute  rest 
in  bed  for  at  least  four  weeks.  All  mental  excitement  must  be 
avoided.  An  ice-bag  is  placed  over  the  region  of  the  stomach  and 
kept  there^almost  continuously  for  two  weeks;  this  prevents  gaseous 
distention  and  promotes  contraction  of  the  walls;  it  also  obviates 
hemorrhage,  and  eases  the  pain  when  pain  is  present.  On  the 
first  day,  even  when  hematemesis  has  occurred,  the  patient  receives 
200  Cc.  (Svij)  of  iced  milk,  in  teaspoonful  doses,  and  two  raw 
eggs — within  the  first  twenty-four  hours.  At  the  same  time 
bismuth  subnitrate  is  given  twice  or  three  times  a  day,  2  Gm.  (30 
grains)  at  a  dose,  and  this  is  continued  for  ten  days.  The  eggs  are 
beaten  up  entire  (with  a  little  sugar),  and  the  cup  containing  them 
is  placed  in  a  dish  filled  with  ice,  so  that  they  remain  cold.  This 
food  at  once  "binds"  the  supersecreted  acid  and  therefore  rapidly 
mitigates  the  pain ;  and  the  vomiting,  which  is  often  quite  trouble- 
some, ceases.  The  portion  of  milk  is  increased  each  day  by  100 
Cc.  (Biij),  and  one  additional  egg  is  given,  so  that  at  the  end  of 
the  first  week  the  patient  is  receiving  800  Cc.  (1^  pints)  of  milk 
and  eight  eggs  daily.  Both  these  foods  are  continued  in  the  same 
amount  for  another  week.  No  more  than  a  liter  (quart)  of  milk 
a  day  is  allowed  at  any  time.  Besides  milk  and  eggs,  some  raw 
chopped  meat  is  given  between  the  fourth  and  the  eighth  day, 
usually  on  the  sixth — 35  Gm.  (Six)  in  small  divided  doses  (stirred 
up  with  the  eggs  or  given  alone);  the  day  after,  70  Gm.  (§ij); 
and  later,  possibly  more  if  the  previous  portions  have  been  well 
digested.    The  patient  is  now  able  to  take  some  rice,  well  cooked, 


TREATMENT 


499 


and  a  little  softened  zwieback.  During  the  third  week  a  mixed 
diet  is  tolerated,  the  meat  being  given  well  cooked  or  lightly  broiled. 
Among  the  advantages  of  the  Lenhartz  method  of  treating  gas- 
tric ulcer  are:  The  avoidance  of  partial  fasting,  so  distressing  to 
many  patients;  the  maintenance  of  body  weight;  and  the  rapidity 
with  which  the  hemoglobin  attains  the  normal  after  hemorrhage  of 
greater  or  less  severity.  On  the  eighth  day  after  a  hemorrhage 
Lenhartz  sometimes  prescribes,  in  addition  to  bismuth,  Blaud's 
iron  in  finely  powdered  form. 

Diet  in  Ulcer  of  the  Stomach  (Lenhartz). 


Days  after  hemorrhage.    . 

Eggs 

Milk  (Cc.)        .  ... 

Sugar  to  the  eggs  (Gm.) 
Raw  beef  (Gm.)    .... 
Milk  rice  (ground  rice)  (Gm.) 
Zwieback  (Gm.)    .... 
Raw  ham  (Gm.)    .... 

Butter  (Gm.) 

Calories 


1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

11 

12 

13 

2 

3 

4 

5 

6 

7 

-8 

8 

8 

8 

8 

8 

8 

200 

300 

KM) 

500 

600 

700 

800 

900 

1000 

1000 

1000 

1000 

1000 

20 

20 

30 

30 

40 

40 

50 

50 

50 

50 

50 

35 

35x2 

35x2 

35x2 

35x2 

35x2 

35x2 

35x2 

100 

100 
20 

200 
40 

200 
40 
50 
20 

300 
60 
50 
40 

300 
60 
50 
40 

300 
80 
50 
40 

280 

420 

637 

777 

955 

1135 

1588 

1721 

2138 

2478 

2941 

2941 

3007 

1 1 


'1000 

50 

!35x2 

400 

100 

50 

40 

'3073 


Sippy  Treatment. —  Neutralization  of  Free  Hydrochloric  Acid  in  the 
Stomach. — B.  W.  Sippy  states  that  after  an  experience  of  twelve 
years  in  the  treatment  of  gastric  and  duodenal  ulcer  on  the  principle 
of  protecting  the  ulcer  from  corrosion  by  the  gastric  juice,  he  is 
convinced  that  the  vast  majority  of  cases  now  treated  surgically 
could  be  readily  cured  by  the  protective  method.  The  reason 
why  a  gastric  ulcer  does  not  heal  as  rapidly  as  an  ulcer  located 
elsewhere  in  the  body  is  that  its  granulating  surfaces  are  periodi- 
cally subjected  to  the  digestive  action  of  the  gastric  juice.  Sippy's 
method  consists  of  hourly  feedings,  and  the  administration  of 
alkalis  between  the  feedings.  A  wide  variety  of  soft  and  palat- 
able foods  is  permitted,  the  basis  of  the  diet  being  milk,  cream,  eggs, 
cereals,  and  vegetable  puree.  The  alkalis  prescribed  are  calcined 
magnesia  (heavy),  sodium  bicarbonate,  and  bismuth  subcarbonate. 
The  antacid  effect  of  the  magnesia  is  greater  and  more  prolonged 
than  that  of  sodium  bicarbonate,  but  its  too  free  employment  is 
apt  to  result  in  diarrhea.  The  bismuth  has,  of  course,  an  astrin- 
gent effect.  The  alkali  prescriptions  alternate — first  magnesia  and 
sodium  bicarbonate,  then  bismuth  subcarbonate  and  sodium  bicar- 
bonate. As  much  as  may  be  required  to  neutralize  the  acidity  is 
administered.  If  there  should  be  excessive  hydrochloric  acid 
secretion  at  night,  this  is  removed  with  the  stomach  tube  each 
night  until  the  irritability  of  the  gastric  glands  has  subsided.  The 
patient  remains  in  bed  three  or  four  weeks.  The  results  obtained 
by  this  method  are,  in  the  words  of  the  writer,1  "almost  beyond 
belief." 

1  B.  W.  Sippy:  Gastric  and  Duodenal  Ulcer,  Journal  of  the  American  Medical 
Association,  May  15,   1915. 


500 


GASTRIC  ULCER 


I  make  use  of  the  following  diet  in  the  manner  outlined  below : 

Diet. 
Soft  or  hard-boiled  eggs. 
Milk. 
Bread. 
Milk  toast. 
Crackers. 

Strained  cereals  with  cream  and  sugar. 
Rice. 
Custard. 
Blanc-mange. 
Junket. 

Plain  ice-cream. 
Mashed  or  baked  potato  with  cream  or  butter. 

8.00  a.m.  Breakfast  consisting  of  food  from  the  above  diet  list. 

9.00  a.m.  Alkali  powder. 

10.00  a.m.  Two  ounces  of  a  mixture  of  half  milk  and  half  cream. 

11.00  a.m.  One  soft  or  hard-boiled  egg. 

12.00  m.  Noon  meal  consisting  of  food  from  the  above  diet  list. 

1.00  p.m.  Alkali  powder. 

3.00  p.m.  Three  ounces  of  a  mixture  of  half  milk  and  half  cream. 

4.30  p.m.  Alkah  powder. 

6.00  p.m.  Evening  meal  consisting  of  food  from  the  above  diet  list. 

7.00  p.m.  Alkah  powder. 

9.30  p.m.  Tumbler  of  half  milk  and  half  cream,  one  hard-boiled  egg,  white 
bread  and  butter. 

If  in  painMuring  the  night,  take  the  alkali  powder. 


r\      f 

F   -.. 

n 

n 

u 

c 


<E>~ 


Fig.  85. — Einhorn  duodenal  tube:  A,  metal  capsule,  the  lower  half  provided  with 
numerous  holes,  the  upper  half  communicating  with  tube  B.  I,  II,  III,  marks  of  40, 
50  and  70  centimeters  from  capsule;  C,  rubber  band  with  silk  thread  attached  to  end 
of  tubing  which  can  be  placed  over  the  ear  of  the  patient;  F,  feeding  syringe;  E, 
flexible  connecting  tube;  D,  three-way  stopcock. 

Einhorn's  Duodenal  Alimentation. — Einhorn  has  devised  an  instru- 
ment, his  so-called  duodenal  tube,  by  which  food  can  be  introduced 
directly  into  the  duodenum  (Fig.  85),  thus  not  only  sparing  the 
stomach  the  work  of  digestion,  but,  what  is  of  more  consequence, 
avoiding  the  accumulation  of  free  hydrochloric  acid  in  this  organ. 
A  small  metal  capsule  (14  mm.  long,  23  mm.  in  circumference), 
perforated,  is  attached  to  a  long  thin  rubber  tube  (8  mm.  in  circum- 
ference and  1  meter  long)  which  is  connected  at  the  other  end  with 
a  feeding  syringe  (Fig.  85). 


tui-:.\tmk\t 


501 


Feeding  is  begun  just  as  soon  as  there  is  no  Longer  any  doubt 
that  the  cud  of  the  tube  has  passed  beyond  the  pylorus.  This 
can  be  easily  ascertained  by  aspirating  some  of  the  fluid  with  the 
syringe.  If  the  contents  are  clear,  this  indicates  gastric  juice, 
while  yellow  or  greenish-yellow  liquid  indicates  duodenal  contents. 
The  food  should  be  introduced  very  slowly,  always  at  body  tem- 
perature, and  at  two-hour  intervals.  After  each  feeding,  water 
should  be  forced  through  the  tube,  and  afterward  a  little  air,  to 
expel  the  contents  of  the  pump  into  the  duodenum,  after  which 
the  stopcock  attachment  of  the  tube  is  closed.  The  tube  may 
remain  in  the  digestive  tract  for  ten  to  fifteen  days  without  caus- 
ing appreciable  irritation  or  discomfort  to  the  patient. 


Fig.  86. — Duodenal  feeding.     (Einhorn.) 

Einhorn's  diet  unit  in  duodenal  alimentation  consists  of  240  Cc. 
(gviij)  of  milk,  one  raw  egg,  and  15  Gm.  (5ss)  of  sugar  of  milk, 
well  beaten.  This  amount  is  administered  at  a  single  feeding. 
Boiled  milk  is  not  coagulated  by  the  secretions  in  the  duodenum. 
Therefore  it  should  be  used  in  all  feedings  with  the  duodenal  tube. 
In  this  manner  the  plugging  of  the  tube  by  coagulated  milk,  which 
would  occur  if  raw  milk  wrere  used,  is  avoided.  When  it  is  desired 
to  introduce  a  greater  quantity  of  wrater  into  the  system  than  that 
taken  during  the  feeding  process,  a  liter  (quart)  of  physiologic  salt 
solution  may  be  given  by  proctoclysis  (see  page  239). 

The  patient  may  be  fed  wdiile  in  the  sitting  posture,  as  illus- 
trated in  Fig.  86,  or  lying  down. 

Method  of  Procedure. — The  capsule  of  the  duodenal  tube  and  the 
lower  part  of  the  rubber  tube  are  moistened  with  wrarm  wrater  and 
placed  in  the  pharynx  of  the  patient.  Then  the  patient  drinks 
a  little  water,  and  the  instrument  soon  passes  into  the  stomach. 


502  GASTRIC  ULCER 

To  be  certain  that  the  capsule  does  not  stick  in  the  esophagus  it 
is  well  to  have  the  patient  shake  his  abdomen,  when  a  syringeful 
of  chyme  can  be  aspirated  if  the  capsule  is  in  the  stomach.  Now 
we  pass  a  syringeful  of  water  and  then  one  of  air  through  the 
instrument.  The  stopcock  is  then  closed  and  the  apparatus  left 
untouched  for  about  an  hour.  The  patient  is  told  not  to  close  his 
mouth  too  tightly,  lest  the  tube  be  retarded  in  its  wanderings. 
He  must  also  avoid  intentional  swallowing.  Through  the  peri- 
stalsis of  the  stomach  the  capsule  is  pushed  on  farther,  and  usually 
passes  through  the  pylorus  into  the  duodenum  and  later  into 
the  upper  part  of  the  small  intestine.  It  is  advisable  to  have  the 
patient  read  some  light  literature  in  order  to  divert  his  attention. 
After  one  hour  we  examine  how  far  the  capsule  has  progressed; 
if  the  mark  III  (indicating  70  centimeters  from  the  capsule)  is 
near  the  lips  or  inside  the  mouth,  we  try  to  aspirate.  If  the  cap- 
sule is  in  the  duodenum,  we  usually  obtain  a  clear  golden-yellow 
or  watery  liquid,  of  alkaline  reaction  and  somewhat  viscid  con- 
sistency. If,  however,  it  is  in  the  stomach,  we  obtain  an  acid  liquid 
resembling  that  first  removed.  This  can,  of  course,  occur  if  the 
tube  lies  coiled  up  in  the  stomach.  Should  the  aspirated  material 
be  acid,  we  must  withdraw  the  tube,  after  putting  water  and  air 
through  it,  as  far  as  the  mark  II  (56  centimeters).  The  tube 
is  then  again  closed,  and  after  one-half  to  one  hour  the  test  pro- 
cedure is  repeated.  The  capsule  in  nearly  all  cases  enters  the 
duodenum  on  the  first  trial.  After  having  fed  the  patient  for  ten 
to  fourteen  days  the  tube  is  closed  and  slowly  withdrawn.  When 
the  esophagus  is  reached  by  the  ascending  capsule  the  patient  is 
told  to  swallow,  and  during  this  act  the  capsule  is  withdrawn.  Both 
gastric  and  duodenal  ulcers  can  be  healed  by  means  of  duodenal 
alimentation. 

The  Morgan  Modification  of  Einhorn's  Duodenal  Alimentation. — 
Morgan  has  suggested  substituting  for  the  foregoing  the  Murphy 
drip  method  (see  page  239)  in  duodenal  feeding.  He  attaches  to 
the  upper  part  of  the  duodenal  tube,  by  means  of  an  additional 
section  of  rubber  tubing,  a  porcelain-lined  irrigator  of  500  Cc.  (1 
pint)  capacity.  The  irrigator  is  placed  at  such  a  height  that  it 
requires  about  an  hour  for  300  Cc.  of  fluid  to  run  through  into  the 
gut.  He  begins  by  giving  90  Cc.  of  the  milk,  egg  and  lactose 
solution  every  two  hours,  and  gradually  increases  so  that  by  the 
end  of  the  first  day  the  patient  is  able  to  take  the  300  Cc.  at  one 
time  with  perfect  comfort.  Morgan's  patients  have  experienced  no 
inconvenience  from  the  continuous  presence  of  the  duodenal  tube 
in  situ,  and  the  feedings  have  frequently  taken  place  while  they 
were  sleeping  and  entirely  without  their  knowledge.  In  addition 
to  the  feeding,  Morgan  gives  500  Cc.  of  normal  salt  solution  per 
rectum,  by  the  drop  method,  thus  adding  to  the  body  fluids  and 
keeping  the  feces  soluble  and  the  bowel  actions  regular. 


TREATMENT 


503 


Medicinal  Treatment. — By  the  administration  of  drugs  in  the 
treatment  of  gastric  ulcer  an  endeavor  is  made  to  stimulate  cica- 
trization, to  cover  and  protect  the  ulcer  from  chemical  irritation, 
and  to  neutralize  the  gastric  acidity,  whether  due  to  the  normal 
acid  or  to  any  of  the  abnormal  acids  of  fermentation. 

In  a  large  percentage  of  cases  of  gastric  ulcer,  pain  can  be  stopped 
by  the  administration  of  sodium  bicarbonate  in  large  dosage.  The 
quantity  required  to  overcome  the  hyperacidity  and  diminish  the 
pain  is  large,  usually  10  to  15  Gm.  .  (5iiss-iv)  a  day.  The  best 
way  of  giving  the  medicine  is  to  dissolve  a  teaspoonful  in  lime- 
water,  add  a  little  spirit  of  peppermint,  and  have  the  patient  sip 
the  solution  teaspoonful  by  teaspoonful  until  the  pain  disappears. 
The  following  prescription  is  serviceable: 


Gm.  or  Cc. 


ulxv 

3ss 
3i 

3ss 


1$ — Spiritus  menthae  piperita  ....  10 

Magnesii  oxidi 2  0 

Sodii  bicarbonatis 4  0 

Cretae  prseparatse 2  0 

Misce. 

Sig. — Stir  a  teaspoonful  in  half  a  tumbler  of  water,  and  sip  slowly,  a  tea- 
spoonful at  a  time,  until  the  pain  is  relieved. 

The  proportion  of  chalk  and  magnesia  will  vary  in  accordance 
with  the  tendency  to  diarrhea  or  constipation  on  the  part  of  the 
patient.  Sodium  bicarbonate  by  itself  has  the  objectionable 
feature  of  easily  forming  sodium  lactate,  sodium  chlorid,  and  other 
purgative  salts.  This  inconvenience  can  be  overcome  with  the 
aid  of  chalk  or  opium.  The  formation  of  sodium  chlorid  is  a 
grave  fault,  'as  this  salt  is  a  constant  source  of  hydrochloric  acid  in 
the  presence  of  gastric  juice.  To  overcome  this  objection  sodium 
bicarbonate  should  always  be  combined  with  other  alkalis  or  inert 
powders  which  may,  in  part  at  least,  prevent  the  formation  of 
sodium  chlorid.  The  following  combinations  are  in  use;  each  is 
for  one  powder,  which  may  be  repeated  four  or  five  times  a  day. 
They  may  be  given  in  alternation,  every  hour,  in  the  endeavor  to 
neutralize  the  hyperacidity,  thus  favoring  the  healing  of  the  ulcer. 


B; — Sodii  bicarbonatis    . 
Calcii  carbonatis 
Bismuthi  subnitratis 

Misce. 


Gm.  or  Cc. 


gr.  xv 
gr.  hj 
gr.  v 


Gm.  or  Cc. 


R, — Sochi  bicarbonatis 0 

Calcii  carbonatis 0 

Pulveris  talci 0 

Bismuthi  sahcylatis 0 

Misce. 

Gm.  or  Cc. 

R/— Sodii  bicarbonatis 0  50 

Cretse  prseparatse 0  25 

Bismuthi  subnitratis 0  25 

Pulveris  opii 0  01 

Misce. 

Gm.  or  Cc. 


6 

gr.  x 

2 

gr.  u] 

3 

gr.  v 

4 

gr.  vi 

R — Sodii  bicarbonatis 0 

Magnesii  oxidi 0 

Pulveris  talci :      .  0 

Pulveris  belladonna?  radicis  0 

Misce.      i 


gr.  vuj 
gr.  iv 
gr.  iv 
gr.  i 


gr.  x 
gr.  hj 
gr-  hj 
gr.  I 


504  GASTRIC  ULCER 

Bismuth  preparations  were  employed  over  a  century  ago  by 
Odier  as  a  panacea  for  spasm  of  the  stomach.  The  use  of  bismuth 
in  the  treatment  of  gastric  ulcer  was  suggested  about  the  middle 
of  last  century  by  Budd  and  Trousseau.  It  remained,  however, 
for  Fleiner,  following  the  advice  of  Kussmaul,1  to  bring  the  bis- 
muth treatment  impressively  to  the  notice  of  the  profession.  The 
method  which  is  strongly  advocated  by  Fleiner  is  as  follows:  The 
stomach  tube  is  discarded  entirely,  and  bismuth  suspensions  (2| 
to  5  drams  of  bismuth  subnitrate  in  a  tumbler  of  warm  water) 
are  taken  by  mouth,  in  the  morning,  on  an  empty  stomach,  the 
latter  having  been  cleansed  three-quarters  of  an  hour  to  an  hour 
previously  with  about  150  Cc.  (5  ounces)  of  Carlsbad  or  Vichy 
water.  The  bismuth  is  given  daily,  the  dose  being  more  or  less 
rapidly  increased,  reduced,  or  discontinued,  according  to  the 
clinical  course.  Breakfast  is  taken  after  half  an  hour's  rest.  The 
bismuth  treatment  should  be  employed  daily  at  the  beginning; 
later,  every  other  day  or  every  third  day.  It  should  be  continued 
as  long  as  necessary  (see  page  265). 

Bismuth  subnitrate  is  a  salt  formed  by  the  combination  of 
bismuth  with  nitric  acid.  Nitric  acid  is  caustic,  antiseptic,  and 
astringent.  Bismuth  subnitrate  is  insoluble  in  water  and  passes 
quite  well  through  the  stomach  into  the  duodenum  without  much 
change.  It  has  been  proved  by  the  Roentgen  ray  that  in  the 
presence  of  ulcer  some  of  the  bismuth  adheres  to  its  raw  surfaces. 
While  adhering,  the  subnitrate  disintegrates  slightly  and  liberates 
some  of  its  nascent  nitric  acid,  which  acts  locally  as  a  stimulant, 
astringent,  and  antiseptic.  The  nascent  nitric  acid  coagulates  the 
albuminous  surface  of  the  ulcer,  which  thus  acts  as  a  protective 
during  the  time  of  healing.  If  the  practitioner  has  this  object  in 
view,  he  should  not  prescribe  bismuth  subnitrate  with  an  alkali, 
for  the  alkali  would  destroy  the  small  quantity  of  nascent  acid 
developed.  It  is  impossible  to  secure  as  good  a  result  in  the  treat- 
ment of  gastric  ulcer  with  any  other  salt  of  bismuth  as  with  the 
subnitrate.  The  inefficiency  of  bismuth  subcarbonate  is  due  to 
the  absence  of  nitric  acid;  in  the  decomposition  of  the  subcarbo- 
nate, carbon  dioxid  is  evolved.  The  chemical  action  of  bismuth 
subnitrate  within  the  stomach  and  duodenum  is  (1)  antisecretory, 
(2)  astringent,  and  (3)  antiseptic.  For  the  better  understanding 
of  these  three  bismuth  effects,  it  is  necessary  to  appreciate  the 
chemical  process  which  takes  place  upon  the  disintegration  of  the 
bismuth  in  the  hydrochloric  acid  gastric  contents.  The  decompo- 
sition of  bismuth  subnitrate  takes  place  according  to  the  following 
formula : 

/N03  /CI 

Bi<         +HC1  =  HN03  +  Bi< 
X)  X0 

1  Charles  D.  Aaron,  The  Healing  of  Gastric  and  Duodenal  Ulcers  with  Bismuth, 
American  Journal  of  the  Medical  Sciences,  October,  1912. 


TREATMENT  505 

It  has  been  found  that  the  effective  constituent  is  not  the  bismuth 
oxid  thus  formed,  but  the  simultaneously  Liberated  nitric  acid; 
the  three  chemical  effects  above  mentioned  are  due  to  this  factor. 
1  have  used  large  doses  of  subnitrate  of  bismuth  in  the  treatment 
of  gastric  and  duodenal  ulcer  for  over  twenty  years,  without  one 
case  showing  symptoms  of  ill  effect.  I  prescribe  it  in  aqueous 
suspension  only,  to  be  taken  before  meals,  three  times  a  day.  The 
bismuth  should  be  continued  for  one  to  four  weeks  during  the  cure. 
I  give  it  as  in  the  following  prescription: 

Gm.  or  Cc. 
1$ — Bismuthi  subnitratis,  c.  p.       ...       6010  5ij 

Aquae  destillatae       .      .      .      q.  s.  ad    240 10  §viij 

Misce. 
Sig.— Shake  well.     Tablespoonful  three  times  a  day,  before  meals. 

Nitrate  of  silver  has  been  used  for  a  long  time  in  the  treatment 
of  gastric  ulcer.  Johnson,  who  was  the  first  to  recommend  it,  had 
observed  that  in  his  cases  of  epilepsy  all  the  gastric  symptoms 
disappeared  after  the  administration  of  nitrate  of  silver.  I  have 
seen  many  cases  in  which  all  gastric  symptoms  caused  by  ulcer 
cleared  up  after  a  course  of  nitrate  of  silver,  and  found  that  the 
silver  salt  acts  favorably  in  cases  in  which  pain  is  present  when 
the  stomach  is  empty.  It  probably  has  the  effect  of  an  antacid 
in  such  cases. 

Gm.  or  Cc. 

I$— Argenti  nitratis 013  gr.  v 

Aquae  destillatae 180 10  5vj 

Misce. 
Sig. — A  tablespoonful  in  a  wineglass  of  distilled  water,  three  times  a  day,  half 
an  hour  before  meals. 

Care  should  be  exercised  in  the  administration  of  silver  salts, 
lest  the  condition  known  as  argyrism  result  from  their  too  long- 
continued  use  (see  page  267) . 

Chronic  ulcer  of  the  stomach  may  keep  up  a  continuous  irri- 
tation of  the  vegetative  nervous  system  (see  page  387).  This 
may  induce  symptoms  of  a  secondary  neurosis  manifested  by 
pylorospasm,  hyperacidity  and  hypersecretion.  We  should  aim  to 
keep  the  stomach  free  from  sensory  irritation  in  order  to  prevent 
spastic  contraction,  and  endeavor  to  promote  local  circulation. 
Atropin  combats  the  neurosis  by  inhibiting  the  impulses  through 
the  vagus,  and  many  cases  are  successfully  treated  with  this  drug 
(see  page  435).  Atropin  sulphate  should  be  administered  morning 
and  evening  for  four  to  six  weeks,  in  the  dosage  of  0.001  to  0.0015 
Gm.  (^  to  4V  grain)  hypodermically  (see  page  271). 

Scarlet  red  has  been  used  for  the  healing  of  gastric  ulcer.  The 
dyestuff  is  not  poisonous  and  can  be  given  without  deleterious 
effect.  It  has  a  stimulating  action  on  epithelial  cell  proliferation. 
Scarlet  red  0.5  Gm.  (7£  grains)  in  capsule  three  times  a  day,  before 
meals,  or  1  per  cent,  in  olive  oil,  may  be  employed. 


506  GASTRIC   ULCER 

I  have  used  tincture  of  iodin,  a  five-drop  dose  in  a  wineglass  of 
water  to  be  taken  three  times  a  day  on  an  empty  stomach.  This 
treatment  has  allayed  the  pain  and  put  the  patient  at  ease  when 
other  therapeutic  agents  were  ineffectual. 

Olive  oil,  owing  to  its  high  nutritive  value  and  its  absolutely 
unirritating  properties,  is  a  therapeutic  agent  worth  a  careful 
trial.  It  has  a  decidedly  restraining  action  upon  hydrochloric 
acid  secretion.  In  recent  cases  of  ulcer  several  spoonfuls  of  the 
oil  may  be  administered  daily,  the  patient  rinsing  the  mouth  with 
some  good  mouth-wash  each  time  after  taking  the  dose.  TJie 
quantity  of  oil  is  gradually  increased  up  to  150  Cc.  (§v)  per  day, 
taken  in  three  portions.  There  is  nothing  to  prevent  giving  nutri- 
ent enemata,  since  the  oil,  as  a  rule,  does  not  cause  diarrhea, 
though  it  usually  relieves  the  constipation  from  which  patients 
with  gastric  ulcer  are  apt  to  suffer.  Generally  in  eight  days  the 
digestive  trouble  disappears,  but  it  is  wise  to  continue  the  oil, 
associated  with  an  appropriate  diet,  for  two  weeks  longer.  This 
treatment  is  particularly  efficacious  in  chronic  ulcer  of  the  stomach, 
even  when  surgery  proves  of  no  avail  (see  page  271). 

For  the  treatment  of  hemorrhage  from  the  stomach,  see  Chapter 
XXVI  on  Gastric  and  Intestinal  Hemorrhage. 

Treatment  by  Antilytic  Serum. — Antilytic  serum  has  recently 
been  employed  with  some  success  in  the  treatment  of  gastric  and 
duodenal  ulcer.  The  serum  of  a  healthy  individual  contains,  in 
addition  to  its  other  constituents,  a  substance  which  stimulates 
the  repair  of  tissue  cells  and  limits  cell  destruction  by  antagonizing 
certain  enzymes  of  fixed  and  wandering  cells.  This  substance  is 
of  the  nature  of  antitrypsin  and  is  attached  to  the  albuminous 
portion  of  the  serum;  it  has  been  called  by  Hort  antilysin.  Anti- 
lytic serum  recommended  for  use  is  the  normal  blood  serum  of 
the  horse,  fresh,  atoxic  and  sterile,  in  the  natural  condition  or  with 
its  antilytic  valency  increased  by  the  addition  of  globulin-free 
serum.  The  treatment  is  applicable  to  cases  of  gastric  ulcer  with 
or  without  hemorrhage.  Complete  rest  in  bed  for  two  or  three 
weeks  must  be  insisted  upon. 

The  antilytic  serum  is  administered  by  mouth  three  or  four 
times  a  day,  immediately  after  meals,  each  dose  in  half  an  ounce 
of  water.  If  pain  is  severe,  60  to  80  Cc.  (gij-iiss)  is  given  in 
divided  doses  in  the  twenty-four  hours.  In  all  severe  cases  the 
serum  treatment  should  be  continued  for  six  weeks.  Marked 
relief  from  pain  has  been  experienced  within  twenty-four  hours 
after  the  beginning  of  the  treatment. 

Treatment  by  Bacterial  Vaccines.— The  treatment  of  gastric  and 
duodenal  ulcer  by  means  of  bacterial  vaccines  was  suggested  to  the 
author  by  the  work  of  Turck  on  the  experimental  production 
of  gastric  ulcer.  Recently  Rosenow  has  been  able  to  produce  in 
the  lower  animals,  by  intravenous  injection  of  living  streptococci 


TREATMENT  507 

resembling  those  found  in  rheumatic  fever  (Streptococcus  viridans), 
ulcer  of  the  stomach  and  duodenum.  The  ulceration  is  due  to 
a  localized  infection  and  secondary  digestion.  The  ulcers  thus 
produced  are  usually  single,  clean,  deep,  bleed  easily,  and  resemble 
the  human  gastric  ulcer  in  many  respects.  In  some  of  the  experi- 
ments cholecystitis  was  induced,  with  the  beginning  formation  of 
gallstones.  Appendicitis  was  also  found.  This  experimental  study 
is  valuable  from  a  therapeutic  viewpoint  when  we  consider  the 
opsonic  work  of  Sir  A.  E.  Wright  and  his  vaccines  made  of  killed 
bacteria.1  It  would  seem  rational  to  use  Streptococcus  viridans 
vaccine  in  the  treatment  of  gastric  ulcer.  Autogenous  bacterial 
vaccines,  or  vaccines  sensitized  by  homologous  serums,  may  be 
used. 

Surgical  Intervention. — The  indications  for  surgical  intervention 
are  as  follows:  (1)  In  sudden  severe  gastric  hemorrhages  threat- 
ening life.  The  ulcer  should  be  excised  in  the  interval.  If  it  is 
possible  to  exactly  locate  the  seat  of  the  ulcer  without  endangering 
the  condition  of  the  patient  through  too  much  handling  of  the 
stomach,  operate  at  once.  (2)  Often-repeated  small  losses  of 
blood  that  cannot  be  checked,  when  the  patient  becomes  anemic 
and  unable  to  take  sufficient  nourishment.  (3)  In  acute  perfora- 
tion, when  the  prognosis  depends  upon  an  early  recognition  of  the 
condition  and  immediate  operation  as  soon  as  the  diagnosis  has 
been  made.  (4)  An  ulcer  situated  at  the  pylorus,  with  ensuing 
stenosis,  stasis,  decomposition  of  the  stomach  contents,  and  derange- 
ment of  the  gastric  mechanism.  (5)  In  patients  who  suffer  from 
pain,  disturbance  of  digestion,  vomiting,  anemia,  melancholia, 
inability  to  work,  and  general  nervous  break-down.  (6)  Gastric 
ulcers  with  formation  of  tumor,  no  matter  where  the  location  may 
be,  always  demand  excision  of  the  tumor. 

The  value  of  gastroenterostomy  in  gastric  ulcer  is  dependent 
upon  the  situation  of  the  ulcer;  the  nearer  it  is  to  the  duodenum  the 
better  the  prognosis.  Operation,  which  under  certain  circum- 
stances is  extremely  grave,  should  be  considered  carefully  and  in 
all  its  aspects  before  being  decided  upon.  Medical  measures  can 
bring  about  relief  and  perhaps  cure  in  a  large  proportion  of  cases, 
particularly  acute  ones.  The  possibility  of  chronic  ulcer  degen- 
erating into  carcinoma  must  be  taken  into  consideration  in  sum- 
ming up  the  indications  for  surgical  intervention.  It  is  better 
when  possible  to  excise  chronic  ulcers,  because  there  is  always  a 
possibility  of  later  carcinomatous  development.  In  a  study  of 
one  thousand  cases  of  gastric  carcinoma,  by  Friedenwald,  7.3 
per  cent,  gave  a  direct  history  of  ulcer.  When  an  ulcer  is  begin- 
ning to  undergo  carcinomatous  change,  the  hyperacidity  and 
secretion  of  gastric  juice  diminish. 

1  Charles  D.  Aaron,  Observations  of  Opsonic  Therapy,  New  York  Medical 
Journal,  December  1,  1906. 


508  GASTRIC   ULCER 

A  simple  uncomplicated  gastric  ulcer  is  not,  in  my  opinion,  a 
case  for  surgical  intervention.  Only  in  the  event  of  complications, 
or  in  ulcers  which  defy  thorough  internal  treatment,  impairing 
nutrition  by  interference  with  motility,  is  there  any  indication  for 
surgical  treatment.  The  fact  should  always  be  taken  into  con- 
sideration that  in  the  present  state  of  the  art  of  diagnosis  we  can 
have  only  a  suspicion  as  to  the  seat  of  the  ulcer.  We  know  that 
four-fifths  of  all  gastric  ulcers  are  situated  at  the  lesser  curvature 
on  the  posterior  wall  of  the  stomach — a  surgically  inaccessible 
place.  Unless,  therefore,  there  is  a  well-developed  ulcer  of  the 
pylorus,  which  has  been  diagnosticated  by  the  signs  of  retention, 
it  is  impossible  to  make  a  safe  prognosis  of  recovery  or  even  of 
improvement  through   surgical  means. 

So  far  as  surgery  is  available,  no  procedure  but  removal  of  the 
ulcer  by  excision  or  gastroenterostomy  is  to  be  considered.  How- 
ever, excisjon  of  the  ulcer  does  not  remove  the  cause  nor  the  ten- 
dency to  re-formation;  nor  does  it  improve  motility.  Neither  does 
it  reduce  hyperacidity;  but  it  does  remove  the  dangers  accom- 
panying the  ulcer,  such  as  hemorrhage,  perforation,  and  malignant 
degeneration.  Gastroenterostomy  and  favorable  drainage  protect 
the  ulcer  from  irritation  by  the  hyperacid  gastric  contents,  and 
some  ulcers  which  have  defied  every  kind  of  treatment  will  heal 
or  become  latent  after  this  operation.  Ulcers  of  the  pylorus  or 
duodenum  can  be  cured  by  gastroenterostomy,  but  no  others. 

It  is  always  necessary  to  pay  special  attention  to  the  diet  after 
stomach  operations  in  order  to  achieve  the  most  favorable  results. 
It  is  certainly  surprising  to  observe  that  a  patient,  compelled 
for  years  to  live  on  milk,  broth,  and  soups,  is  allowed  at  once  to 
partake  of  roast  beef  and  potatoes.  It  is  an  overestimation  of 
surgical  effect  to  suppose  that  a  stomach  which  has  been  seriously 
impaired  for  a  number  of  years  can  suddenly  develop  normal  func- 
tion. It  is  irrational  to  allow  such  a  patient  to  get  out  of  bed 
after  a  couple  of  weeks  and  to  discharge  him  as  cured  at  the  end 
of  three  weeks.  After  the  operation  a  careful  dietary  should  be 
maintained  for  weeks  and  even  months;  the  surgeon  should  be 
assisted  in  the  care  of  such  convalescents  by  an  internist.  This 
course,  together  with  the  simultaneous  use  of  alkalis,  affords  the 
best  security  against  recurrence,  especially  at  the  jejunum,  in 
which  location  ulcer  is  apt  to  develop  as  a  sequela  of  gastroenter- 
osotomy. 

When  dyspeptic  symptoms  are  persistent,  following  the  surgical 
operation  of  gastroenterostomy,  it  has  been  found  that  duodenal 
alimentation  (see  page  500)  gives  most  gratifying  results.  Adhe- 
sions, or  small  ulcers  of  the  stomach  or  the  jejunum  in  the  vicinity 
of  the  new  stoma,  are  the  most  frequent  conditions  causing  the 
new  disturbances.  Duodenal  alimentation  should  always  be  carried 
out  before  submitting  the  patient  to  further  surgical  measures. 


(  OMPLICATIONS  5()«) 

Complications. — One  of  the  most  frequent  complications  of  gas- 
tric nicer  is  hemorrhage.  Such  hemorrhages  can  usually  be  stopped 
by  internal  measures  (see  Chapter  XXVI),  and,  if  these  should 
tail,  operative  intervention  is  not  likely  to  help  (see  page  520). 

Perforation  in  Gastric  Ulcer. — Statistics  show  that  the  site  of 
gastric  ulcer  is,  as  a  rule,  on  the  posterior  wall  of  the  stomach, 
yet  perforations  occur  most  frequently  from  ulcers  on  the  anterior 
wall.  They  break  by  sloughing  through  the  anterior  wall  directly 
into  the  peritoneal  cavity.  A  sudden  severe  burning  pain  in  the 
epigastric  or  umbilical  region  is  often  the  first  symptom  of  a  per- 
foration. The  pain  is  characteristic,  inasmuch  as  it  never  shoots 
from  one  part  of  the  abdomen  to  another,  but  remains  localized. 
Frequently  it  is  so  severe  as  to  compel  the  patient  to  cry  out,  and 
is  often  followed  by  collapse,  sudden  pallor,  a  quick,  feeble  pulse, 
cold,  clammy  skin,  and  anxious  countenance.  The  passage  of  air 
from  within  the  stomach  into  the  peritoneal  cavity  will  imme- 
diately produce  an  effect  on  the  sympathetic  nerves,  resulting  in 
shock,  when,  owing  to  the  obtunded  senses,  pain  disappears. 
Acute  pain,  fall  of  temperature,  rapid  pulse,  vomiting,  tender- 
ness in  the  epigastrium,  rigidity  and  shock,  demand  immediate 
surgical  intervention.  The  operation  may  be  very  simple  for 
perforation  at  the  greater  or  lesser  curvature  or  at  the  anterior 
wall  of  the  stomach.  If  the  perforation  has  taken  place  at  the 
posterior  wall  the  operation  is  most  difficult  and  usually  does  not 
do  any  good. 

The  statistics  in  perforation  show  such  unfavorable  results  from 
internal  treatment  that  it  seems  imperative  to  resort  at  once  to 
surgery  unless  there  are  very  important  considerations  to  contra- 
indicate  it.  About  one-half  of  the  ulcer  patients  who  have 
successfully  gone  through  an  operation  for  perforation  remain 
quite  well  for  years,  fully  capable  of  work,  and  practically  free 
from  gastric  symptoms.  Only  a  small  proportion  develop  severe 
ulcer  symptoms. 

Subphrenic  Abscess. — Subphrenic  abscess  following  perforation 
should  likewise  be  operated  upon  as  soon  as  possible.  The  most 
frequent  cause  of  such  suppuration  is  gastric  ulcer;  it  is  rare  to 
find  it  following  any  other  disease.  The  abscess  may  also  be 
subhepatic   or   retrocolic. 

Pyloric  Stenosis. — The  surgically  most  important  complication 
of  gastric  ulcer  is  benign  pyloric  stenosis  with  subsequent  dilata- 
tion of  the  stomach  (see  Chapter  XXIV).  The  operations  for 
the  relief  of  benign  obstruction  of  the  pylorus  are:  pyloroplasty, 
gastrojejunostomy,  and  gastroenterostomy.  The  method  and  selec- 
tion of  the  operation  will  depend  upon  the  conditions  at  the  time 
of  operation. 

Hypertrophic  Stenosis  of  the  Pylorus. — Hypertrophic  stenosis  of 
the  pylorus  has  been  successfully  operated  upon  in  very  young 


510  GASTRIC   ULCER 

children.  As  experience  in  these  cases  accumulates  we  find,  how- 
ever, that  internal  treatment  is  often  efficient  and  surgical  inter- 
vention not  often  required.  An  important  point  to  remember  in 
this  connection  is  that  we  do  not  know  how  the  operative  result 
accomplished  in  young  children  will  regulate  itself  in  advancing 
years. 

During  the  past  few  years  it  has  been  found  that  the  Ramm- 
stedt  operation  is  the  one  -  generally  adopted.  This  consists  in 
incising  in  a  longitudinal  direction  the  thickened  and  hardened 
pylorus  through  the  muscularis  down  to  the  mucosa  without  open- 
ing the  latter. 

In  congenital  hypertrophic  stenosis  of  the  pylorus,  a  child  at 
birth  seems  well  nourished,  but  soon  begins  to  vomit  its  food. 
The  quantity  of  vomited  material  increases  from  day  to  day;  and 
alteration  of  food,  modified  or  peptonized  milk,  seems  to  have 
little  or  no  influence  on  the  vomiting,  which  continues  regardless 
of  the  quantity  of  food  taken.  By  the  use  of  the  stomach  tube  we 
find  that  if  there  is  no  vomiting  the  food  taken  is  retained  in  the 
stomach  a  long  time.  The  weight  of  the  child,  meanwhile,  con- 
tinues to  decrease  and  the  little  patient  looks  old  and  wrinkled. 
Constipation  is  usually  present.  The  tongue  and  mouth  are 
moist  and  clean.  Upon  inspection  the  abdomen  is  found  to  be 
flat,  and  a  peristaltic  wave  can  be  seen  to  pass  over  the  stomach. 
Frequently  the  stomach  contents  may  be  outlined  through  the 
abdominal  wall  and  the  visible  waves  of  peristalsis  easily  made 
out.     An  epigastric  tumor  points  to  pyloric  stenosis. 

A  rare  condition  found  in  babies  is  due  to  an  infection  through 
the  omphalomesenteric  duct  and  urachus  that  induces  adhesions 
of  the  liver  and  duodenum,  pulling  the  pylorus  up  and  kinking  it 
in  such  a  way  as  to  give  symptoms  of  pyloric  stenosis. 


CHAPTER  XXVI. 
GASTRIC  AND  INTESTINAL  HEMORRHAGE. 

Many  different  conditions  may  cause  gastric  or  intestinal  hemor- 
rhage. Bleeding  in  the  stomach  may  take  place  without  any 
visible  symptoms.  This  can  also  be  said  of  hemorrhage  in  the 
bowel.  Unless  patients  complain  of  hematemesis  or  melena,  they 
rarely  consult  a  physician  until  signs  of  intense  anemia  appear. 

Diagnosis. — The  diagnosis  of  gastric  hemorrhage  is  usually  not 
a  difficult  matter.  There  is,  as  a  rule,  hematemesis,  accompanied 
or  followed  by  melena.  Hemorrhages  from  the  mouth  and  respi- 
ratory tract,  in  which  the  blood  has  been  carried  to  the  stomach 
by  swallowing,  must  be  excluded.  Due  inquiry  must  be  made 
in  regard  to  possible  prior  and  causative  injuries  to  the  head,  or 
coincident  affections  of  the  lungs.  In  gastrorrhagia  there  are 
usually  some  circumstances  which  indicate  the  exclusively  gastric 
nature  of  the  trouble;  in  almost  every  instance  there  is  a  history 
of  stomach  disturbance,  often  of  long  duration,  preceding  the 
hemorrhage.  Hemorrhage  without  any  previous  symptoms  is 
rare.  Furthermore,  the  history  and  clinical  symptoms  render 
the  diagnosis  fairly  easy  as  to  the  particular  disease  causing  the 
hemorrhage,  whether  gastric  ulcer,  superficial  ulceration,  capillary 
bleeding,  or  carcinoma.  Gastric  hemorrhage  may  occur  in  the 
following  conditions:  Venous  or  varicose  hemorrhage  in  cirrhosis 
of  the  liver  or  obstruction  to  the  portal  circulation;  parenchyma- 
tous gastric  hemorrhage  in  diseases  of  the  heart,  liver,  or  blood; 
acute  and  chronic  gastritis;  stenosis  of  the  pylorus;  miliary  aneu- 
rysm; injury  from  foreign  bodies  in  the  stomach;  caustic  poisons 
in  the  stomach;  syphilis;  arteriosclerosis;  septicemia;  rupture  of 
abscesses  or  of  an  aneurysm  of  neighboring  structures  into  the 
stomach;  anemia  and  disturbances  of  menstruation  (vicarious 
gastric  hemorrhage);  hemorrhoids;  neurogenous  disturbances 
(hysteria,  gastric  crises);  and  cholelithiasis.  Intestinal  hemor- 
rhage occurs  either  as  severe  acute  hemorrhage  (in  which,  as  a 
rule,  considerable  quantities  of  blood  are  lost)  or  as  a  chronic 
condition  during  the  course  of  which  small  quantities  of  blood  are 
lost  at  different  times.  The  mildest  form  of  hemorrhage  is  that 
in  which  mere  traces  of  blood  appear  in  the  feces.  Hemorrhage 
may  occur  in  cases  of  ulcer,  stenosis,  ileus,  malignant  tumor, 
cirrhosis  of  the  liver,  embolism  of  various  sized  branches  of  the 
mesenteric  artery  or  thrombosis  of  the  corresponding  veins,  and 
hemorrhoids. 


512  GASTRIC  AND  INTESTINAL  HEMORRHAGE 

Gastric  ulcer  is  the  most  common  cause  of  hemorrhage  from  the 
stomach,  occurring  in  5  per  cent,  of  the  entire  population,  accord- 
ing to  Ewald  and  others.  Hematemesis  occurs  in  at  least  40  per 
cent,  of  all  cases  of  gastric  ulcer,  and  many  authorities  place  the 
proportion  much  higher.  In  a  study  of  1000  cases  of  gastric  ulcer, 
Friedenwald  found  hemorrhage  in  only  22  per  cent.  It  is  fatal  in  8 
per  cent,  of  the  cases  in  which  it  occurs,  according  to  the  conserva- 
tive estimate  of  Leube,  and  we  cannot  question  that  it  is  indirectly 
fatal  in  a  much  greater  number  of  cases  through  anemia  and  its 
remote  consequences. 

Severance  of  the  omental  bloodvessels  leads  to  thrombosis  in 
them,  which  may  extend  back  some  distance  from  the  point  of 
origin.  This  thrombosis  may  occlude  such  vessels  as  the  gastro- 
omental,  gastric,  and  others.  The  breaking-off  of  emboli  and 
their  lodgment  in  the  veins  of  the  stomach  and  intestine  frequently 
occurs.  This  is  followed  by  necrosis  and  ulceration  of  the  parts 
supplied  by  these  vessels,  and  often  by  fatal  secondary  hemorrhage. 

Differential  Diagnosis. — The  differential  diagnosis  of  doubtful 
cases,  as  between  gastric  and  duodenal  hemorrhage,  is  a  matter 
fraught  with  great  difficulty.  The  following  symptoms  indicate 
a  duodenal  origin  of  the  bleeding:  (1)  Pain  about  one  to  three 
hours  after  meals,  which  is  relieved  by  the  taking  of  food;  (2) 
considerable  melena,  associated  with  hematemesis  or  existing 
alone;  (3)  the  pain  is  often  in  the  right  hypochondriac  region. 

Prophylaxis. — Only  in  cases  in  which  the  diagnosis  is  ascertained 
with  certainty,  in  gastric  ulcer  or  carcinoma  in  which  hemorrhage 
may  be  anticipated,  are  prophylactic  measures  likely  to  avail. 
In  such  cases  occult  hemorrhages  frequently  precede  hematemesis. 
The  stools  should  be  examined  frequently  for  occult  blood.  Con- 
cealed gastric  hemorrhage  is  of  very  frequent  occurrence,  not  only 
in  gastric  ulcer,  but  more  especially  in  carcinoma  of  the  stomach, 
in  which  the  patients  often  "bleed  to  death,  as  it  were,  by  drops," 
without  the  knowledge  of  the  physician.  A  very  careful  analysis 
of  the  feces  and  gastric  contents  in  all  cases  in  which  there  is  the 
least  cause  for  suspicion  is  recommended;  the  patient,  meanwhile, 
should  be  placed  upon  a  meat-free  diet.  On  discovery  of  occult 
blood  in  the  stools  the  patient  should  be  placed  at  rest  in  bed;  the 
diet  should  be  exclusively  liquid,  preferably  milk,  and  the  quantity 
should  be  gradually  increased  until,  at  the  end  of  eight  days, 
three  liters  (quarts)  a  day  are  being  consumed.  The  patient 
should  maintain  the  recumbent  posture  until  no  further  signs  of 
hemorrhage  are  evident  from  an  examination  of  the  stool  (see 
page  123). 

Treatment. — Visible  {manifest)  or  macroscopic  gastrorrhagia  is 
characterized  by  hematemesis,  tarry  stools  (melena),  or  both.  In 
the  treatment  of  this  condition  the  first  indication  is  to  stop  the 
bleeding;  the  second,  to  combat  the  condition  producing  the  hem- 


TREATMENT  513 

orrhage.  The  patient  must  be  placed  absolutely  at  rest  in  bed, 
in  the  dorsal  position.  An  ice-bag  suspended  by  a  frame,  to 
avoid  pressure,  is  placed  over  the  epigastrium;  this  will  have  an 
analgesic  effect  and  conduce  to  the  comfort  of  the  patient.  When 
the  patient  is  suffering  much  pain  and  is  very  restless  and  sleep- 
less, morphin  hypodermically  will  often  bring  immediate  relief. 
It  must  be  given  in  substantial  doses  to  be  effectual,  0.015  to 
0.03  Gm.  (^  to  |  grain)  every  three  or  four  hours.  The  addition 
of  atropin  0.0006  Gm.  (y^nr  grain)  relaxes  the  spasm.  Codein 
phosphate  0.02  to  0.06  Gm.  (f  to  1  grain)  may  be  given  instead 
of  morphin. 

Suppositories  of  extract  of  belladonna  0.0075  Gm.  (f  grain) 
and  extract  of  opium  0.03  to  0.06  Gm.  (§  to  1  grain)  are  likewise 
effective.  Absolute  abstinence  from  food  is  necessary,  thus  keep- 
ing the  stomach  at  rest  not  only  physically  but  physiologically. 
Thirst  is  to  be  counteracted  by  small  pieces  of  ice  in  the  mouth  and 
by  rinsing  the  mouth  with  water.  Proctoclysis  or  hypodermocly- 
sis  of  physiologic  salt  solution  is  an  excellent  means  of  quench- 
ing the  thirst.  It  is  rather  doubtfid  whether  nutrient  enemata 
should  be  given  as  a  prophylactic  measure  against  inanition  from 
continuous  hemorrhage.  Nutrient  enemata  always  cause  the 
patient  to  move  about  and  induce  increased  peristalsis.  Bodily 
movements  should  be  avoided.  Instead,  therefore,  of  nutrient 
enemata,  proctoclysis  should  be  employed  (see  page  239).  When 
the  hemorrhages  are  moderate  in  amount,  nutrient  enemata  may 
be  resumed  earlier  than  in  the  severer  cases.  While  the  hemor- 
rhage is  in  progress  the  ice-bag  should  be  replaced  at  night  by  a 
Priessnitz  bandage.  Hot  compresses  should  not  be  employed  after 
recent  hemorrhages. 

Should  the  quantity  of  blood  lost  be  large,  normal  saline  must 
be  administered  by  hypodermoclysis  or  by  intravenous  injection. 

Treatment  by  Lavage. — A  number  of  writers,  among  them  Ewald, 
recommend  lavage  of  the  stomach  with  ice-water  to  remove  clots 
and  at  the  same  time  to  act  as  a  styptic. 

Kaufmann  believes  that  gastric  lavage  is  the  most  expedient 
means  in  the  treatment  of  severe  hemorrhage  from  gastric  ulcer, 
provided  it  be  carefully  applied.  It  relieves  overdistention  by 
removing  the  stagnating  masses  of  accumulated  blood,  acid  secre- 
tions, food  remnants,  and  gas,  which  are  usually  present  in  such 
cases,  and  which  not  only  give  rise  to  nausea  and  pain  but  act  as 
a  constant  source  of  irritation  to  the  mucous  membrane,  inducing 
hypersecretion  and  thus  increasing  the  amount  of  gastric  contents. 
The  removal  of  this  material  allows  the  emptied  stomach  to  con- 
tract, and  this  aids  in  the  occlusion  of  the  eroded  vessel.  The 
thrombus  ordinarily  formed  does  not  usually  fill  the  opening  of 
the  bloodvessel  completely.  Lavage  removes  such  inefficient 
thrombi  and  gives  the  bleeding  vessel  a  chance  to  contract  and 
33 


514  GASTRIC  AND  INTESTINAL  HEMORRHAGE 

form  a  more  efficient  thrombus.  With  a  carefully  performed 
lavage  there  should  be  no  danger  of  causing  perforation  by  over- 
distention;  the  amount  of  water  in  the  stomach  at  any  one  time 
should  be  comparatively  small,  and  if  perforation  from  the  patho- 
logic process  should  occur  the  cleansing  of  the  stomach  will  prove 
beneficial,  since  it  prevents  the  entrance  of  gastric  contents  into 
the  peritoneum.  It  is  well  known  that  the  prognosis  in  perfora- 
tion is  best  when  the  perforation  takes  place  at  a  time  when  the 
stomach  is  empty  (see  page  197). 

After  lavage,  large  doses  of  crystalline  bismuth  subnitrate 
should  be  administered.  Bismuth  in  crystalline  form  is  sup- 
posed to  adhere  more  tenaciously  to  the  surface  of  the  ulcer  than 
the  ordinary  amorphous  form,  so  that  the  blood  is  agglutinated 
to  the  bismuth  mass.  Bismuth  is  not  sufficiently  astringent  to 
contract  the  bloodvessels  and  thereby  stop  the  hemorrhage;  it 
does,  however,  aid  in  the  coagulation  of  the  blood,  at  the  same  time 
exercising  a  soothing  influence  upon  the  gastric  mucous  membrane 
(see  page  517). 

Treatment  by  Enemata. — Hot-water  enemata  have  been  employed 
with  favorable  results.  The  enema  consists  of  ^  liter  (1  pint)  of 
water  at  120°  F.;  this  should  be  given  three  times  a  day.  The 
object  is  to  produce  reflex  anemia  in  the  upper  portions  of  the 
intestine.  Hot  enemata  promptly  check  intestinal  hemorrhage  in 
typhoid  fever,  as  they  do  bleeding  from  the  rectum,  sigmoid,  and 
colon  (see  page  220). 

Medicinal  Treatment. —  Hemostatics. — Ergot  has  a  direct  hemo- 
static action  and  should  always  be  given  subcutaneously.  The 
following  prescriptions  have  been  found  useful: 

Geo.,  or  Cc. 

~Bj, — Extracti  ergotae       .......       10  gr.  xv 

Aquae  destiEatse 5  0  Tfllxxx 

Phenolis  liquefacti 0  06  TT\ j 

Misce. 

Sig. — Fifteen  to  thirty  minims  to  be  injected  subcutaneously. 

Gm.  or  Cc. 

1^ — Extracti  ergotae 2 1 5  gr.  xxxviiss 

Glycerini, 

Aquae aa       5|0  THlxxx 

Misce. 

Sig. — Fifteen  to  thirty  minims  several  times  daily,  hypodermically. 

Emetin  hydrochloride  has  proved  of  great  value.  It  acts  on  the 
smooth  fibers  in  the  bloodvessels,  causing  them  to  contract,  and 
thus  reduces  the  congestion  and  the  bleeding.  It  may  be  admin- 
istered hypodermically,  0.02  Gm.  (|  grain)  twice  daily  for  two  or 
three  days. 

Hvdrastin  hvdrochloride  is  less  effective: 


1^ — Hydrastinae  hydrochloridi 

Aquae 

Misce. 

Sig. — Fifteen  to  thirty  minims,  hypodermically. 


Gm.  or  Cc. 

015 

gr.  vuss 

4|0 

5j 

TREATMENT  515 

The  employment  of  gelatin  is  more  promising.  Sterile  gelatin 
is  furnished  to  physicians  in  strengths  of  10  per  cent,  and  20  per 
cent.  It  is  marketed  in  sealed  glass  tubes,  ready  for  use,  and  is 
liquefied  by  placing  the  tubes  in  hot  water.  It  is  then  taken  up  by 
means  of  a  large  syringe  directly  from  the  glass  tube,  and  injected 
subcutaneously:  40  Cc,  containing  10  per  cent,  of  gelatin,  consti- 
tutes a  single  dose  for  adults;  in  obstinate  cases  this  may  be  repeated 
several  times.  Strict  aseptic  precautions  must  be  observed.  Gela- 
tin injections  do  not  give  rise  to  symptoms  of  anaphylaxis,  as  serum 
injections  sometimes,  though  very  rarely,  do.  Gelatin,  like  horse 
serum,  increases  the  globulin  and  promotes  coagulability  of  the 
blood.  The  slow  instillation  into  the  rectum  of  a  saline  solution 
containing  1  per  cent,  of  gelatin  has  been  found  of  considerable 
value  in  intestinal  hemorrhage.  A  combination  of  calcium  chlorid 
with  sterilized  gelatin  has  been  prepared  under  the  trade  name  of 
kalzine.  Subcutaneous  injection  of  kalzine  is  said  to  give  good 
results  in  hemorrhage. 

The  action  of  gelatin  is  supposed  to  be  due  to  its  lime  salts; 
lime  acts  as  a  hemostatic.  In  severe  hemorrhages  chlorid  of  lime 
has  been  employed  in  5  to  10  per  cent,  solution  in  the  form  of 
small  rectal  enemata — 10  to  12  Cc.  (2  or  3  fluidrams)  every  two 
or  three  hours.  Wright  recommends  calcium  lactate,  to  be  admin- 
istered by  mouth,  1  or  2  Gm.  (15  to  30  grains)  three  times  a  day. 
It  may  be  administered  hypodermically  in  the  same  doses. 

Another  preparation  is  stypticin,  which  is  injected  in  10-per-cent. 
watery  solution,  subcutaneously,  1  or  2  Cc.  (15  to  30  minims) 
three  times  a  day.     Good  results  have  been  claimed  for  it. 

Blood  transfusion  has  been  found  to  be  an  excellent  hemostatic 
in  any  severe  hemorrhage  that  cannot  be  controlled  by  the  usual 
methods.  The  increase  of  blood  coagulation  and  the  stimulation 
of  capillary  contraction  are  due  to  active  thrombin  in  the  blood 
of  the  donor  which  is  usually  lacking  in  the  recipient.  Thrombo- 
kinase  is  present  in  the  juices  of  all  tissues.  When  a  bloodvessel 
is  injured,  thrombokinase  is  secreted  and  unites  with  the  throm- 
bogen  of  the  blood,  forming  the  fibrin  ferment  to  which  coagulation 
is  due.  Blood  or  blood  serum  can  be  used  to  stop  hemorrhage. 
From  10  to  20  Cc.  (5iiss-v)  of  human  blood  serum  may  be  in- 
jected intravenously  and  the  dose  repeated  several  times.  The 
blood  can  be  kept  in  a  sterile  bottle  in  the  ice-box  for  a  few  days, 
and  the  serum  used  when  required.  Human  serum  is  safer  than 
horse  serum,  since  the  latter  may  possibly  cause  anaphylactic 
reactions. 

During  the  recent  war,  when  blood  transfusion  was  impossible, 
good  results  were  obtained  by  the  intravenous  injection  of  Locke's 
or  Ringer's  solution  containing  5  per  cent,  of  acacia. 

By  precipitating  normal  horse  serum,  a  sterile,  soluble,  anhy- 
drous powder  containing  the  fibrin  ferment  necessary  for  clotting 


516  GASTRIC  AND  INTESTINAL  HEMORRHAGE 

the  blood  has  been  obtained.  This  hemostatic  ferment  is  sold 
under  the  trade  name  coagulose.  It  is  readily  soluble  in  cold 
water,  and  it  possesses  the  great  advantage,  as  compared  with 
liquid  serum,  of  retaining  its  coagulating  principle  unimpaired 
for  long  periods  of  time.  It  has  been  used  with  success  in  hemor- 
rhage from  the  stomach  and  intestine. 

Coagulose  is  supplied  in  15-Cc.  (|  ounce)  glass  bulbs  which  con- 
tain 0.65  gram  (10  grains)  of  the  desiccated  powder,  equivalent 
to  10  Cc.  (|  ounce)  of  blood  serum.  Before  being  used,  it  is 
necessary  to  add  to  the  powder  in  the  bulb  8  to  10  Cc.  of  sterile 
water,  the  temperature  of  which  should  not  be  above  that  of  the 
blood.  The  solution  may  be  injected  subcutaneously  at  any  con- 
venient point.  One  dose  consists  of  the  contents  of  one  bulb. 
If  the  bleeding  is  not  entirely  controlled  within  half  an  hour  a 
second  dose  should  be  given  within  two  or  three  hours.  In  per- 
sistent hemorrhages  three  or  four  injections  may  be  given  daily 
for  several  days,  and  these  should  be  continued  for  a  short  period 
after  the  hemorrhage  ceases. 

It  has  long  been  recognized  that  the  formation  of  blood  clot 
depends  upon  the  evolution  of  fibrin  from  the  fibrinogen  of  the 
blood,  through  the  action  of  a  ferment,  thrombin.  Thrombin 
does  not  exist  as  such  in  the  blood,  but  is  present  as  prothrombin, 
and  is  kept  in  this  antecedent  state  by  the  action  of  a  neutraliz- 
ing substance,  designated  antithrombin.  Under  proper  conditions 
the  antithrombin  is  neutralized  and  thrombin  released,  bringing 
about  the  phenomenon  of  blood  clot  by  acting  upon  the  fibrinogen. 

"Hemostatic  serum"  is  a  sterile  serum  derivative  composed 
principally  of  prothrombin,  thrombokinase  and  anti-antithrombin 
in  physiologically  balanced  solution.  It  is  a  clear,  light-amber 
colored  liquid,  and  is  physiologically  adapted  to  intravenous,  sub- 
cutaneous, intraspinous  or  intraperitoneal  injection.  It  is  indicated 
in  the  treatment  of  all  types  of  hemorrhage,  and  is  of  particular 
value  in  cases  depending  upon  faulty  coagulation  of  the  blood.  The 
average  dose  is  1  to  2  Cc,  given  intravenously  or  subcutaneously. 
In  known  hemophilic  cases  the  proper  dose  is  5  Cc.  The  injection 
should  be  repeated  every  four  to  six  hours  until  perfect  control  is 
established. 

Thromboplastin  is  the  trade  name  of  a  solution  of  thromboplas- 
tic  substances  normally  found  in  the  brain  of  the  ox.  It  is  a  liquid 
extract  and  its  activity  is  said  to  be  due  to  the  presence  of  kephalin, 
a  useful  hemostatic  agent.  The  fibrin  ferment  action  is  said  to 
become  manifest  in  one  to  two  minutes,  and  the  clot  is  decidedly 
firmer  than  that  which  occurs  spontaneously.  Thromboplastin 
may  be  administered  by  mouth  in  gastric  and  intestinal  hemor- 
rhage in  the  dose  of  20  Cc.  diluted  with  300  Cc.  (10  ounces)  of  water. 

Kephalin  is  an  ether-alcoholic  extract  of  brain  substance  evap- 
orated until  the  residue  is  a  yellow  lipoid.     It  is  not  destroyed 


TREATMENT  517 

by  boiling.  For  use  by  mouth  or  intramuscular  injection  the 
dose  is  10  to  30  drops  in  physiologic  saline  solution,  repeated 
every  four  to  sixteen  hours.  Its  action  is  similar  to  that  of  throm- 
boplastin. 

By  fractional  centrifugalization  of  animal  blood,  a  natural 
physiologic  styptic  consisting  of  blood  platelets  has  been  obtained; 
it  is  sold  under  the  trade  name  coagulen.  It  can  be  dispensed  in 
powder  or  tablet  form,  and  is  put  up  as  a  solution  in  ampoules 
especially  for  subcutaneous  or  intravenous  injection.  In  giving 
coagulen  intravenously  the  injection  should  be  made  very  slowly, 
and  discontinued  at  once  if  any  headache,  cardiac  pain  or  eye 
derangement  appears. 

Extracts  of  the  pituitary  and  the  thyroid  gland,  administered 
in  small  doses,  the  former  hypodermically,  have  a  hemostatic 
effect.  Epinephrin  is  recommended,  in  solution  of  1  to  1000,  1 
or  2  Cc.  (15  to  30  drops)  by  mouth,  two  or  three  times,  at  short 
intervals,  the  day  of  the  hemorrhage. 

In  collapse  after  profuse  hemorrhage,  caffein  may  be  given : 

Gm.  or  Cc. 

3— Caffeinse 3)0  gr.  xlv 

Aqua? ad     30 10  gj 

Misce. 

Sig. — Fifteen  to  thirty  minims,  hypodermically. 

When  the  hemorrhage  has  ceased  for  several  days  and  exami- 
nation of  the  feces  shows  a  complete  cessation  of  occult  bleeding, 
the  administration  of  more  copious  nutrient  enemata  is  indicated. 
Feeding  by  mouth  may  now  be  begun.  The  quantity  of  milk 
should  be  gradually  and  slowly  increased,  so  that  about  1  liter 
(quart)  will  be  consumed  on  the  eighth  day  after  the  cessation  of 
the  hemorrhage.  When  the  hemorrhage  is  due  to  gastric  or  duo- 
denal ulcer,  the  "Leube  cure"  or  "Lenhartz  cure"  may  be  insti- 
tuted at  this  period  (see  Chapter  XXV). 

Drugs,  as  a  rule,  play  a  subordinate  part  in  the  treatment  of 
hemorrhage  from  gastric  ulcer,  especially  when  proper  dietetic 
treatment  can  be  instituted  and  carried  out.  When,  however, 
patients  must  be  treated  while  following  their  usual  occupations, 
or  when  pains  persist  in  spite  of  dietetic  measures,  medication 
proves  especially  valuable. 

Bismuth  in  the  form  of  one  of  its  salts  is  employed  probably 
more  extensively  than  any  other  drug  in  the  treatment  of  hemor- 
rhage of  the  stomach  and  intestine.  The  bismuth  salts  owe  their 
efficacy  to  their  slightly  astringent  effect,  which  promotes  granu- 
lation at  the  surface  of  the  ulcer.  Animal  experimentation  has 
shown  that  bismuth  stimulates  the  secretion  of  mucus,  which, 
together  with  the  salt  itself,  forms  a  protective  .film  upon  the 
denuded  portions  of  the  gastro-intestinal  mucous  membrane. 
This  covering  is  capable  of  protecting  the  ulcerated  points  from 


518  GASTRIC  AND  INTESTINAL  HEMORRHAGE 

irritation  by  both  food  and  gastric  juice.  The  bismuth  mean- 
while becomes  oxidized,  changing  into  the  dioxid  of  bismuth. 
Under  this  bismuth  crust  the  formation  of  granulation  tissue  can 
proceed  without  interruption,  resulting  in  the  so-called  bismuth 
eschar.  Since  the  bismuth  preparations  are  astringent,  they  dimin- 
ish secretion,  mitigate  the  severity  of  pain,  and  arrest  hemorrhage. 
A  single  large  dose  is  usually  effectual.  Bismuth  suspension, 
consisting  of  30  grams  (1  ounce)  of  bismuth  subnitrate  in  60  Cc. 
(2  ounces)  of  water,  may  be  given  (see  page  504). 

One  of  the  most  lauded  hemostatics  for  the  treatment  of  gastric 
hemorrhage  is  escalin,  introduced  by  G.  Klemperer.  This  is  a 
paste  of  finely  powdered  aluminum  in  glycerin,  and,  according  to 
Klemperer,  it  possesses  the  property  of  arresting  bleeding  more 
effectually  than  other  means.  It  has  been  found  that  escalin 
stimulates  the  secretion  of  gastric  juice,  and  the  general  conclu- 
sion has  been  that  its  administration  cannot  be  considered  a  valu- 
able addition  to  the  therapeutic  measures  at  our  disposal  for 
arresting  hemorrhages  of  the  stomach. 

Silver  nitrate  is  similar  in  its  action  to  bismuth.  In  the  treat- 
ment of  conditions  associated  with  gastric  hemorrhage  we  begin 
with  a  solution  of  0.25  Gm.  (4  grains)  in  120  Cc.  (4  ounces)  of 
distilled  water,  one  tablespoonful  to  be  taken  three  times  a  day 
when  the  stomach  is  empty.  The  strength  of  the  solution  is 
gradually  increased  to  0.3  Gm.  (5  grains)  in  120  Cc.  (4  ounces). 
The  stronger  solution  should  be  continued  for  five  days.  Finally, 
a  solution  of  0.4  Gm.  to  120  Cc.  (6  grains  in  4  ounces)  is  taken, 
the  dose  being  the  same  as  before  (one  tablespoonful).  In  the 
meantime  the  Leube  method  of  treatment  should  be  followed  (see 
page  267). 

Analgesics. -^Analgesic  drugs,  such  as  morphin,  codein,  atro- 
pin,  and  extract  of  belladonna,  may  be  administered  with  bismuth 
powders: 

Gm.  or  Cc. 

1$ — Codeinee  phosphatis 0  [03  gr.  ss 

Extracti  belladonna? 0  02  gr.  § 

Bismuthi  subnitratis 2|00  gr.  xxx 

Misce  et  ft.  pulv.  no.  i;  mitte  x. 

Sig. — One  powder  three  or  more  times  a  day. 

Atropin  has  been  employed  with  advantage  in  the  treatment 
of  gastric  hemorrhage  due  to  slow-healing  ulcers,  with  hyper- 
acidity, hypersecretion,  and  motor  disturbances  (see  page  435). 
Subcutaneous  injections  of  atropin  have  produced  favorable 
results,  though  the  drug  is  not  directly  hemostatic;  the  effect  is 
due  to  its  inhibitory  action  on  the  vagus.  The  hemorrhagic 
blood  effused  into  the  stomach  acts  as  a  stimulus  to  the  secretion, 
and  thus  the  coagula  closing  up  the  bleeding  vessels  are  constantly 
redissolved  by  the  gastric  juice;  if  atropin,  by  suppressing  the 
secretion,  prevents  the  thrombotic  coagula  from  being  dissolved, 


Gm.  or  Co. 

1 

4 
150 

0 
0 
0 

TTlxv 

5i 

Bv 

TREATMENT  519 

it  may  be  said  to  act  indirectly  as  a  hemostatic  agent.  At  the 
beginning  of  treatment  patients  are  given  1  milligram  UV  grain) 
of  atropin  sulphate  hypodermically  morning  and  night.  If 
required,  however,  'A  or  4  milligrams  (-jnr  to  tV  grain)  may  be 
administered  during  the  twenty-four  hours.  Atropin,  by  inhibit- 
ing hypersecretion,  has  a  marked  influence  on  pain.  Its  admin- 
istration may  be  continued  for  four  to  eight  weeks.  The  chief 
untoward  effects  complained  of  by  patients  are  dryness  of  the 
mouth  and  indistinct  vision  resulting  from  the  cycloplegic  action 
of  the  drug  (see  page  271). 

Chloroform-water  (1:120),  one  tablespoonful  every  two  hours, 
may  be  given  when  slight  pains  are  present.  Chloroform  may  be 
prescribed  in  combination  with  bismuth  also: 


R, — Chloroformi 

Bismuthi  subnitratis 

Aquae q.  s.  ad 

Misce. 

Sig. — One  tablespoonful  to  be  taken  every  hour. 

Cocain  may  be  made  use  of  in  the  presence  of  pain  and  obstinate 
vomiting.  Orthoform  and  anesthesin  are  valuable  analgesic  rem- 
edies. The  prompt  effect  of  orthoform  in  relieving  the  pain  of  ulcer 
associated  with  hemorrhage  has  been  noted  (see  page  270) . 

Lenhartz  recommends  the  following  pill  in  the  treatment  of  the 
severe  anemias  resulting  from  gastric  hemorrhage: 

Gm.  or  Cc. 
R, — Ferri  sulphatis, 

Potassii  carbonatis  .   aa     15 [0  5ss 

Tragacanthse,  q.  s. 
Misce  et  ft.  pil.  no.  c. 
Sig. — Three  pills  three  times  a  day. 

Iron  in  this  form  is  sometimes  badly  borne,  which  fact  has  led 
to  the  introduction  of  other  iron  preparations.  Fersan  has  been 
described  on  page  188.  I  prefer  the  hypodermic  method  of 
administering  iron  (see  page  581). 

As  a  tonic  and  hematinic  for  the  relief  of  the  anemic  and  ema- 
ciated condition  of  the  patient  the  following  may  be  prescribed 
with  great  benefit: 

B, — Ferri  sulphatis  exsiccati     . 

Mangani  dioxidi, 

Quininas  bisulphatis      .... 

Extracti  nucis  vomica? 

Extracti  gentianse  .... 

Misce  et  ft.  caps.  no.  i;  mitte  1. 
Sig. — One  capsule  four  times  daily. 


Gm. 

or  Cc. 

0 

06 

gr-  J 

0 
0 
0 

1 

01 

14 

gr.  iss 

gr-  s 
gr.  lj 

520  GASTRIC  AND  INTESTINAL  HEMORRHAGE 

For  controlling  persistent  intestinal  hemorrhage,  tincture  of  iodin 
frequently  gives  gratifying  results: 

Gm.  or  Co. 

1$ — Tincturse  iodi 1 10  TTlxv 

Sodii  iodidi 0  1.  gr.  ij 

Aquae  menthse  piperitae, 

Syrupi  simplicis aa     20  [0  5v 

Misce. 

Sig.— -Teaspoonful  every  hour. 

Hyperchlorhydria  not  infrequently  precedes  gastric  hemorrhage. 
To  counteract  this  condition,  bismuth  subnitrate  is  recommended 
in  large  doses  after  meals,  wrapped  in  wafers  or  suspended  in 
mucilage.     The  following  combination   is  of  value: 


Gm.  or  Cc. 

1$ — Sodii  bicarbonatis 0  1 5-1 

Magnesii  oxidi 0 

Bismuthi  subnitratis 1 

Cretae  praeparatae 0 

Misce  et  ft.  chart,  no.  i;  mitte  xx. 

Sig. — One  powder  after  each  meal. 


0  gr.  viii-xv 

65  gr.  x 

30  gr.  xx 

25  gr.  iv 


Constipation  may  occur  with  the  administration  of  the  foregoing, 
and  under  such  circumstances  a  saline  laxative  would  be  indicated 
(see  page  284) . 

Operative  Treatment. — Acute  hemorrhage  is  not  a  condition  that 
lends  itself  to  surgical  treatment.  It  can  usually  be  stopped  by 
internal  treatment;  and  if  this  should  fail,  operative  intervention 
is  not  likely  to  help.  Less  than  5  per  cent,  of  the  cases  die  of  these 
hemorrhages  without  operation.  By  subjecting  patients  to  opera- 
tion we  expose  them  to  further  dangers  to  which  they  easily  suc- 
cumb; while  without  operation  they  have  a  reasonable  chance  to 
recover.  This  view  is  shared  by  a  large  number  of  experienced 
surgeons.  With  internal  treatment  Lenhartz  reports  201  cases  of 
gastric  hemorrhage  with  a  mortality  of  3  per  cent.,  Ewald  166 
cases  with  a  mortality  of  4.87  per  cent.,  and  Wirsberg  320  cases 
with  a  mortality  of  5.9  per  cent.  If  energetic  prolonged  internal 
treatment  should  not  be  successful  in  checking  chronic  oozing  of 
blood — as  can  easily  be  observed  by  daily  examination  of  the 
feces  with  the  benzidin  test  for  occult  blood — operative  treatment 
should  be  advised.  In  hemorrhage  from  ulcer,  either  resection 
of  the  ulcer,  or,  where  this  is  impossible,  gastroenterostomy,  should 
be  performed.  The  latter  operation  frequently  stops  the  hemor- 
rhage, especially  if  the  ulcer  be  situated  at  the  pylorus.  In  pyloric 
ulcer,  however,  it  is  not  the  hemorrhage,  but  the  stenosis,  which 
renders  operation  necessary. 


CHAPTER  XXVII. 
EROSIONS;  PERIGASTRITIS. 

EROSIONS  OF  THE  STOMACH. 

Forms. — Acute  or  Hemorrhagic  Erosions. — These  are  small  abra- 
sions of  the  gastric  mucosa  which  extend  partly  through  this 
layer.  They  are  usually  multiple.  They  occur  in  the  new-born; 
in  chronic  diseases  of  the  heart  or  arteries;  in  acute  infections  with 
the  pneumococcus;  and  in  septic  infection.  Hemorrhagic  erosions 
of  the  gastric  mucous  membrane  are  sometimes  complications  of 
chronic  gastritis  in  its  early  stages. 

Chronic  Erosions  of  the  Stomach. — Einhorn,  who  was  the  first 
to  describe  gastric  erosions  as  a  clinical  entity,  defines  the  condi- 
tion as  one  in  which  the  gastric  mucous  membrane  becomes  the 
seat  of  small  superficial  exfoliations. 

Gerhardt  says  that  in  erosions  of  the  stomach,  as  shown  bi- 
section, almost  the  entire  lower  stratum  of  the  mucous  membrane 
is,  as  a  rule,  normal.  In  the  epithelium  of  these  remaining  glands 
nothing  remarkable  can  be  discovered;  at  the  sides  the  glands 
become  longer;  the  first  ones  that  are  intact  usually  curve  them- 
selves over  the  defect  and  partly  cover  it.  Recovery  seems  to  take 
place  by  the  simple  aftergrowth  of  the  gland  remnants. 

Etiology. — The  exact  etiology  of  erosions  of  the  stomach  is 
obscure.  Einhorn  reports  association  of  the  condition  with  hyper- 
chlorhydria,  but  the  vast  majority  of  cases  have  been  ascribed  to 
chronic  gastritis.  The  same  factors  which  predispose  to  gastritis 
are  sometimes  associated  with  erosions  of  the  stomach,  but  in 
most  cases  of  gastritis  there  is  no  evidence  of  erosions.  In  many 
cases  in  which  gastritis  could  be  excluded,  Turck  found  erosions 
of  the  mucous  membrane.  He  claims  also  to  have  found  them, 
in  the  same  cases,  in  other  locations — mouth,  pharynx,  colon;  and 
many  a  so-called  ulcer  of  the  rectum  presents  more  of  the  symp- 
toms of  erosion  than  of  ulcer.  In  lavage  of  the  colon,  particles 
are  found  in  the  wash-water  similar  to  the  specimens  of  mucous 
membrane  found  in  the  wash-water  from  the  stomach  of  the  same 
patients. 

There  are  a  number  of  predisposing  conditions.  Children  who 
have  been  ill-fed  and  those  who  do  not  appropriate  the  full  nutri- 
tion of  their  food,  the  vascular  walls  losing  "tone"  though  the 
body  weight  may  not  suffer,  are  more  or  less  subject  to  erosion 
of  the  stomach.    The  abuse  of  alcohol  is  another  predisposing 


522  .      EROSIONS— PERIGASTRITIS 

factor.  Chlorosis  may  play  an  important  part  in  the  causation  of 
erosions.  It  would  appear  that  erosions  result  from  obstruction 
of  the  circulation  to  the  stomach,  combined  with  irritation  of  the 
gastric  mucosa. 

Symptoms. — Pain  is  the  most  pronounced  symptom.  This 
comes  on  after  partaking  of  food,  irrespective  of  the  kind.  The 
pain  of  erosions  differs  from  that  of  gastric  ulcer,  inasmuch  as  it 
is  not  intense,  never  boring  or  cramp-like,  though  Pariser  states 
that  in  the  cases  under  his  observation  the  pains  were  described 
as  "unbearable  suffering."  It  is  probable  that  the  annoying  con- 
stancy of  this  symptom  impresses  the  patient  with  a  sense  of  great 
severity.  Pain  comes  on  immediately  after  eating,  persists  for 
an  hour  or  two,  then  gradually  subsides.  In  some  cases  it  persists 
all  the  time,  irrespective  of  the  ingestion  of  food.  Lavage  usually 
dispels  the  pain.  Frequently  patients  have  no  appetite.  In  some 
cases  vomiting  is  one  of  the  distressing  symptoms.  Control  inves- 
tigation of  the  fasting  stomach,  in  order  to  differentiate  erosions 
from  gastric  ulcer  or  from  a  neurosis,  is  necessary. 

Patients  lose  weight  at  the  beginning  of  their  illness,  but  after 
that  the  weight  is  fairly  constant.  The}'  present  a  picture  of 
emaciation,  protruding  jaws  and  hollow  cheeks,  but  not  the  cachexia 
which  characterizes  carcinoma  and  the  severe  wasting  diseases. 
Patients  with  gastric  erosions  complain  of  weakness  and  inability 
to  work,  a  feeling  that  is  most  marked  directly  after  meals. 

Diagnosis. — The  most  important  diagnostic  feature  of  gastric 
erosions  is  the  presence  in  the  water,  after  lavage,  of  small  pieces 
of  gastric  mucous  membrane.  Einhorn  describes  them  as  3  or 
4  mm.  long,  about  the  same  width,  and  of  a  blood-red  color. 
Under  the  microscope  well-preserved  glands  and  accumulations  of 
red  blood-corpuscles  may  be  seen.  Blood  is  almost  never  found 
in  the  washings  which  contain  membranous  exfoliations.  This  is 
explained  by  the  probability  that  the  pieces  of  gastric  mucosa  peel 
off  some  little  time  before  the  performance  of  lavage.  When  the 
return  water  is  tinged  with  blood,  this  is  the  result  of  coughing 
which  violently  contracts  the  stomach.  It  is  difficult  to  ascertain 
whether  the  exfoliations  are  from  the  same  spots  day  by  day,  or 
from  different  locations  (see  page  97) . 

Pathology. — The  pathology  of  erosions,  according  to  Ewald 
(who  has  studied  it  soon  after  the  death  of  the  patient),  presents 
the  following  picture:  "The  ducts  of  the  glands  were  packed  full 
of  red  blood-cells,  having  their  origin  from  hemorrhages  on  the 
surface  of  the  mucous  membrane,  which  in  turn  could  only  have 
some  from  the  capillary  network  situated  close  to  the  free  surface 
of  the  mucous  membrane.  They  develop  into  little  hemorrhagic 
erosions,  small  streak-like  or  rounded  losses  of  substance,  from  the 
size  of  a  millet  seed  to  that  of  a  pea,  on  which  at  times  a  blackish- 
brown  extravasation  of  blood  is  found,  together  with  a  simulta- 


EROSIONS  OF  THE  STOMACH  523 

neous  loosening  of  the  mucous  membrane."  In  the  majority  of 
cases  there  is  a  decrease  in  the  hydrochloric  acid  secretion.  Jn 
some  there  is  more  or  less  profuse  secretion  of  mucus. 

Prognosis. — The  course  of  the  disease  is  usually  prolonged, 
extending  sometimes  over  several  years.  There  are,  however, 
intervals  of  improvement. 

Treatment. — The  dietetic  treatment  depends  upon  the  results  of 
analysis  of  the  gastric  contents.  The  condition  of  the  secretion 
determines  whether  the  case  shall  be  treated  as  subacid  gastritis 
or  hyperchlorhydria.  The  alkalis  are  indicated  in  hyperacidity; 
the  vegetable  bitters  in  cases  characterized  by  a  deficiency  of 
hydrochloric  acid  secretion. 

There  is,  as  a  rule,  marked  muscle  weakness;  consequently  food 
is  apt  to  remain  longer  in  the  stomach  than  is  normal.  Time  must 
be  given  for  one  meal  to  pass  through  the  pylorus  into  the  intestine 
before  a  second  meal  is  taken.  It  is  well  to  advocate  two  meals 
a  day,  one  in  the  morning  and  one  at  night.  There  may  be  some 
distress  in  the  beginning  from  the  loss  of  the  noonday  meal,  but 
this  is  purely  a  question  of  habit,  and  the  patient  soon  becomes 
accustomed  to  taking  two  meals  daily,  feeling  more  comfortable. 
With  great  loss  of  motor  power  dietetic  measures  must  be  observed. 
Chopped  meat  and  white  bread  are  all  that  is  desirable  in  the 
beginning.  We  may  gradually  add  to  this,  chicken,  fish  (boiled  or 
baked,  not  fried),  sweetbread  and  calf's  brain.  Vegetables  may 
be  added  later — potatoes,  squash  and  mashed  turnips. 

General  Treatment. — The  indication  for  general  treatment 
is  the  equalization  of  the  circulation,  for  which  the  hot  bath  and 
extension  movements  can  be  employed.  The  patient  is  placed  in 
the  bath  at  105°  F.,  and  the  temperature  is  rapidly  increased  to 
110°  to  115°  F.  When  his  skin  has  become  reddened  he  is  taken 
from  the  bath  and  rubbed  with  ice.  The  ice  further  stimulates 
circulation  and  reduces  the  temperature  caused  by  the  heat  of  the 
bath. 

Local  Treatment. — The  local  treatment  of  the  stomach  in 
gastric  erosions  is  of  great  importance. 

1.  Nitrate  of  Silver. — Pain  in  this  condition  is  best  relieved  by 
lavage  with  a  0.5-per-cent.  solution  of  nitrate  of  silver,  after  rinsing 
out  the  fasting  stomach  with  lukewarm  water.  The  silver  solution 
should  be  permitted  to  remain  in  the  stomach  for  about  a  minute; 
on  its  removal  the  lavage  is  repeated  with  lukewarm  normal  salt 
solution.  This  treatment  may  be  employed  every  other  day  for 
ten  to  twelve  days,  or  until  all  particles  of  mucous  membrane 
have  disappeared  from  the  stomach  contents  (see  page  267) . 

The  following  prescription  has  been  found  useful : 

Gm.  or  Cc. 

1^ — Argenti  nitratis 0  j  25  gr.  iv 

Aquae  destillatse       .      .      .      q.  s.  ad    240 10  gviij 

Misce. 
Sig. — Tablespoonful  three  times  a  day,  before  each  meal. 


524  EROSIONS— PERIGASTRITIS 

2.  The  Bismuth  Treatment. — This  consists  of  lavage  every  other 
day  with  an  alkaline  solution,  to  dissolve  mucus,  and  the  admin- 
istration of  bismuth  subnitrate  in  doses  of  1  to  2  Gm.  (15  to  30 
grains)  three  times  a  day  (before  meals)  (see  page  265). 

Gm.  or  Cc. 

3^ — Bismuthi  subnitratis 3010  Bj 

Aquse  chloroformi    .      .      .      q.  s.  ad    240 10  oviij 

Misce. 
Sig. — Tablespoonful  three  times  daily,  before  each  meal. 

3.  Suprarenal  Gland. — Einhorn  recommends  desiccated  supra- 
renal gland.  He  administers  it  every  other  day  in  powder  form — 
about  0.2  Gm.  (3  grains).  When  this  is  used  the  nitrate-of-silver 
douche  is  omitted. 

Stockton  and  Jones  recommend  attention  to  the  general  health 
and  advise  strychnin,  arsenic,  malt  and  cod-liver  oil,  fresh  air,  sun- 
light, mountain  climbing  and  other  invigorating  exercise,  to  be 
used  appropriately. 

PERIGASTRITIS. 

Perigastritis  is  an  inflammation  of  the  peritoneal  coat  of  the 
stomach.  It  may  develop  in  the  course  of  ulcer  of  the  stomach,  in 
two  forms,  namely:  as  a  loose  adhesion  between  the  stomach  and 
neighboring  organs,  whereby  the  former  is  subjected  to  traction; 
and  as  a  tumor-like  infiltration  caused  by  the  gradual  advance  of 
the  ulcer  toward  the  abdominal  wall. 

The  local  inflammation  runs  a  latent  course,  and  the  symptoms 
are  obscured  by  the  more  pronounced  pains  of  the  gastric  ulcer. 
Perigastric  adhesions  are  caused  by  ulceration  of  the  stomach  and 
duodenum,  gallstones  in  the  gall  bladder  or  bile  ducts,  trauma- 
tism, malignant  disease,  pancreatic  disease,  umbilical  hernia,  and 
possibly  tuberculosis  and  syphilis.  The  adhesions  are  usually  to 
the  pancreas,  liver,  or  spleen.  Adhesions  to  the  anterior  abdominal 
wall  are  very  rare.  Symptoms  due  to  adhesions  arise  usually  in 
cases  where  the  attachment  is  to  one  of  the  more  mobile  organs, 
which  drags  on  the  adhesions.  Liver  or  pancreas  adhesions  are 
usually  short  and  broad;  those  to  the  colon  or  gall  bladder  may  be 
long  and  cord-like.  The  shape  of  the  stomach  may  be  markedly 
or  only  slightly  altered.  The  pylorus  may  be  narrowed,  or  the 
stomach  may  be  nearly  divided  into  two  parts — hour-glass  stomach. 
Other  effects  are:  dilatation  by  traction,  and  interference  with 
motility  and  contracting  power. 

Hour-glass  Contraction. — Hour-glass  stomach  is  a  condition  in 
which  the  stomach  is  divided  into  two  cavities.  It  may  be  either 
congenital  or  acquired.  The  hour-glass  stomach,  so-called,  is 
caused  by  perigastric  adhesions  or  gastric  ulcer.  The  diagnosis 
depends  in  the  main  upon  the  use  of  the  stomach  tube,  when  by 
inspection  one  may  be  able  to  see  that  the  fluid  introduced  into  the 


PERIGASTRITIS  .")2.") 

stomach  through  the  stomach  tube  produces  a  ballooning  or  prom- 
inence of  one  pari  of  the  stomach,  and  that  this  prominence  sud- 
denly subsides  and  after  a  gurgling  noise  another  swelling  shows 
itself  in  the  other  part  of  the  stomach.  The  Roentgen  ray  and  the 
bismuth  meal  afford  the  best  means  of  diagnosis  (see  Plate  XV, 
Fig.  2). 

Symptoms. — The  history  of  the  case  is  usually  a  long  6ne,  and  the 
symptoms  finally  complained  of  are  not  infrequently  preceded  by 
others  more  characteristic  of  gastric  ulcer  or  gallstone  colic.  Pain 
is  the  most  common  and  characteristic  symptom,  and  a  marked 
feature  is  the  fact  that  it  is  frequently  confined  to  one  locality. 
It  is  usually  greatly  influenced  by  the  position  of  the  patient,  but 
very  little  by  food.  Violent  exertion  often  brings  on  the  pain; 
it  is  sometimes  relieved  by  firm  pressure  or  bandaging.  Local 
tenderness  is  usually  present.  The  secretion  of  gastric  juice  is 
normal. 

Forms. — Among  the  varieties  of  perigastritis  are: 

1.  Local  Adhesive  Growths,  which  may  or  may  not  give  rise  to 
distressing  symptoms.— These  adhesions  may  cause  pain  of  greater 
or  less  severity,  especially  when  the  adhesive  bands  are  subjected 
to  traction  by  various  bodily  movements  (walking,  gymnastics) 
or  the  distention  of  the  stomach  wTith  food.  The  adhesions  may 
result  in  disturbing  the  motility  of  the  stomach.  The  diagnosis 
is  often  difficult,  since  little  or  nothing  can  be  elicited  by  palpa- 
tion. A  diagnosis  of  perigastritis  is  warranted  when,  after  the 
healing  of  a  gastric  ulcer,  the  painful  symptoms  persist,  or  when 
the  usual  treatment  of  the  stomach  for  disturbances  of  motility 
does  not  lead  to  improvement. 

2.  Perigastritis  with  the  Formation  of  Tumors. — When  the  symp- 
toms of  gastric  ulcer  persist  for  months  or  years,  a  tumor  becomes 
apparent  in  the  left  epigastric  region.  The  growth  of  the  tumor  is 
gradual,  and  the  mass  is  often  adherent  to  the  anterior  abdominal 
wall.  Vomiting  is  frequently  a  symptom.  It  may  not  be  possible 
to  exclude  the  alternative  of  malignancy  until  after  a  somewThat 
extended  period  of  observation. 

Diagnosis. — Roentgen  fluoroscopy  is  of  great  value  in  the  diag- 
nosis of  perigastritis.  Exploratory  laparotomy  is  an  acknowledged 
and  necessary  measure  for  the  recognition  and  cure  of  this  condi- 
tion. Adhesions  from  gastric  ulcer  are  by  no  means  uncommon; 
in  the  postmortem  room  about  45  per  cent,  of  the  cases  of  gastric 
ulcer  show  more  or  less  adhesion  to  neighboring  organs.  Fen- 
wick's  table  of  123  cases  shows  the  pancreas  and  liver  to  be  the 
organs  most  frequently  involved  in  the  adhesions.  Adhesion 
to  the  pancreas  frequently  saves  the  patient  from  the  danger  of 
perforation.  In  cases  of  perigastric  adhesions  little  or  no  loss  of 
flesh  is  observed;  the  condition  is  seldom  fatal.  The  paroxysmal 
character  of  the  pain  is  supposed  to  be  due  to  peristalsis,  which 


526  EROSIONS—PERIGASTRITIS 

causes  a  dragging  upon  the  adhesions.  It  is  thought  that  many 
cases  of  " gastralgia,"  "hysteria/'  or  "hypochondriasis,"  if  care- 
fully investigated,  would  be  found  to  be  due  to  intra-abdominal 
adhesions.  Local  tenderness  is  sometimes  elicited,  and  more 
rarely  still  the  matting  together  of  the  organs  can  be  made  out  by 
palpation.  Severe  pain,  in  fact,  is  the  most  prominent  symptom. 
It  must  be  remembered,  of  course,  that  perigastric  adhesions  and 
an  unhealed  gastric  ulcer  may  be  associated.  When  the  symptoms 
are  due  entirely  to  the  adhesions,  the  pain  is  apt  to  be  constant 
and  of  long  duration,  more  pronounced  when  the  stomach  is  empty 
than  when  it  is  full;  it  is  not  produced  or  increased  by  the  taking 
of  food.  The  situation  of  the  adhesions  will  also  influence  the 
symptoms.  For  instance,  if  a  band  passes  from  the  stomach  to 
the  colon,  the  contraction  of  either  of  these  organs  will  cause 
severe  pain;  but  if  a  large  area  of  the  stomach  is  fixed  to  the  pan- 
creas, it  is  not  likely  that  the  pain  will  be  severe.  The  history 
of  an  old  gastric  ulcer  is  of  the  greatest  value. 

In  regard  to  adhesions  and  perigastritis  we  are,  unfortunately, 
able  to  make  a  diagnosis  in  only  a  very  small  percentage  of  cases. 
Perigastritis,  unless  there  is  a  distinct  disturbance  of  motility,  is 
rarely  a  sufficient  reason  for  surgical  intervention.  When  firm 
immovable  tumors  can  be  palpated  in  the  epigastrium,  and  carci- 
noma can  be  excluded,  the  existence  of  adhesions  or  epigastric 
hernia  may  be  suspected.  Adhesions  may  or  may  not  interfere 
with  the  motility  of  the  stomach.  Those  not  interfering  may  be 
wisely  left  undisturbed,  for  we  all  know  that  severed  adhesions 
are  likely  to  re-form.  In  rare  cases  there  may  be  an  adhesion  near 
the  pylorus,  predisposing  to  dilatation,  that  leads  us  to  believe 
we  have  a  case  of  organic  obstruction  of  the  pylorus.  Morris  has 
called  our  attention  to  adhesions  around  the  liver,  which  he  calls 
"cobwebs,"  that  may  cause  many  symptoms  of  indigestion.  When 
these  adhesions  occur  around  the  stomach,  interfering  with  motil- 
ity, they  may  produce  symptoms  suggesting  dilatation.  The 
methods  of  examination  mentioned  in  Chapter  XXIV  on  Motor 
Insufficiency  will  help  us  in  the  diagnosis. 

Treatment.- — Prophylaxis  consists  in  the  early  diagnosis  of  gastric 
ulcer  and  its  early  cure,  for  the  sooner  an  ulcer  heals  the  less  oppor- 
tunity is  there  for  the  formation  of  adhesions.  Of  therapeutic 
agents,  only  fibrolysin  and  thiosinamin  are  worthy  of  considera- 
tion. These  drugs  may  be  used  in  the  less  severe  forms  of  adhe- 
sions, cicatricial  stenosis,  and  the  so-called  "hour-glass  contraction." 
The  treatment  of  cicatricial  stenosis  by  fibrolysin  has  been  described 
(see  page  484).  The  so-called  hour-glass  stomach  is  to  be  treated 
in  other  respects  as  motor  insufficiency  of  the  second  degree  (see 
Chapter  XXIV). 

When  a  diagnosis  of  perigastritis  has  been  made  with  reasonable 
certainty,  too  much  time  should  not  be  spent  with  internal  medi- 


PERIGASTRITIS  527 

cation,  inasmuch  as  surgical  intervention  is  indicated.  In  simple 
adhesions  good  results  have  been  obtained  by  simply  breaking  them 
up.  When  the  condition  is  complicated  with  motor  disturbance, 
a  gastroenterostomy  should  be  performed.  The  perigastric  tumor 
must  be  treated  surgically.  It  is  important  for  the  surgeon  to 
bear  in  mind  that  there  may  be  two  ulcers  and  therefore  two  sets 
of  adhesions  in  the  same  case.  When  the  adhesions  cannot  be 
separated  it  may  become  necessary  to  perform  pyloroplasty  or 
gastrojejunostomy. 

Promotion  of  visceral  movement  is  the  most  efficient  means  of 
preventing  adhesion  of  raw  peritoneal  surfaces — movement  in  bed, 
general  massage,  and  mild  laxatives. 


CHAPTER  XXVIII. 
ARTERIOSCLEROSIS;  SYPHILIS;  TUBERCULOSIS. 

ARTERIOSCLEROSIS. 

Arteriosclerosis  consists  of  a  thickening  of  the  intima  as  a 
result  of  primary  changes  in  the  media  and  adventitia.  The 
sclerotic  condition  may  be  diffuse  or  circumscribed;  later  in  the 
progress  of  the  disease  it  involves  the  media  and  adventitia. 

Sclerosis  of  the  abdominal  arteries  may  be  responsible  for  any 
one  of  the  three  following  pathologic  manifestations: 

1.  Gastric  Hemorrhages. — The  cause  of  the  hemorrhages  is 
miliary  aneurysm  of  the  gastric  arterioles,  developing  on  sclerotic 
bases.  The  diagnosis  can  be  made  with  a  reasonable  degree  of 
probability  only  in  patients  of  advanced  age  who  are  affected  with 
a  general  arteriosclerosis.  The  treatment  of  this  form  of  hemor- 
rhage is  the  same  as  that  of  gastrorrhagia  from  other  causes. 

2.  Gastric  Ulcer. — This  condition  is  likely  to  supervene  in  vas- 
cular areas  in  which  the  blood  supply  has  become  defective  in 
consequence  of  sclerotic  obliteration  of  the  arterioles.  The  treat- 
ment is  that  of  the  round  or  peptic  ulcer. 

3.  Abdominal  Angina. — Pain  of  a  severe  and  paroxysmal  nature 
sometimes  follows  sclerosis  of  the  abdominal  aorta  and  its  branches. 
The  attacks  are  apt  to  take  place  at  night  after  bodily  exertion 
or  mental  excitement. 

Etiology.— Among  the  important  factors  producing  sclerotic 
changes  in  the  arteries  are: 

1.  Old  Age.- — Arteriosclerosis  is  preeminently  a  disease  of  the 
later  years  of  life,  when  it  occurs  as  an  involution  process,  an 
expression  of  the  natural  wear  and  tear  to  which  the  arteries  are 
subjected.  Longevity  is  largely  a  vascular  question;  the  rela- 
tionship is  well  expressed  in  the  adage,  "A  man  is  as  old  as  his 
arteries." 

2.  Toxic  Factors. — Alcohol,  lead  poisoning  and  gout  are  impor- 
tant factors  in  the  causation  of  arteriosclerosis. 

3.  Syphilis. — Syphilis,  inherited  or  acquired,  is  a  most  important 
cause  of  sclerotic  changes  in  the  arteries  of  the  young  and  the 
middle-aged. 

4.  Overeating. — Overeating  is  an  important  etiologic  factor. 

5.  Overwork. — Muscular  overwork  or  prolonged  and  severe  exer- 
cise tends  to  produce  hypertension  of  the  arteries  by  increasing 
the  peripheral  resistance. 


ARTERIOSCLEROSIS  529 

6.  Toxemia. — As  to  the  poisons  generated  by  the  ordinary  bac- 
teria of  the  intestine,  Metchnikoff  believes  that  his  experiments 
have  now  established  beyond  question  that  small  doses  of  para- 
cresol  and  indol,  acting  on  the  organism  over  a  longer  or  shorter 
period,  are  capable  of  inducing  chronic  lesions  of  a  sclerotic  nature. 
Such  lesions  are  the  very  ones  that  are  most  frequently  encountered 
in  senility.  His  latest  experimental  and  chemical  research  demon- 
strates further  that  the  phenols  and  indol  found  in  the  stool  and 
urine  are  not  the  excreta  of  our  tissues,  but  the  products  of  per- 
manent microbian  flora.  It  is  not  unreasonable  to  assume  that 
the  digestive  tract  can  constantly  harbor  an  injurious  flora,  the 
source  of  chronic  poisoning,  leading  to  arteriosclerosis.  (See 
Chapter  XXXIX.)  | 

Pathology. — The  changes  to  be  described  under  this  heading  are 
of  a  degenerative  character,  and  have  an  important  bearing  upon 
the  integrity  of  the  arterial  walls  as  well  as  upon  the  viscera  supplied 
by  the  sclerosed  arteries. 

Owing  to  the  proliferation  of  endothelium  and  to  an  increase  in 
the  connective  tissue  of  the  intermediate  layer,  a  thickening  of  the 
intima  results,  which  may  wholly  or  practically  occlude  the  lumina 
of  small  arteries.  In  the  large  arteries  the  new  tissue  may  form 
beneath  the  endothelium  diffusely  or  in  circumscribed  masses. 
The  endothelium  may  remain  intact  or  it  may  undergo  various 
changes;  it  may  proliferate,  or  it  may  become  fatty  or  necrotic. 
The  newly  formed  fibrous  tissue  of  the  intima  is  apt  to  undergo 
fatty  degeneration,  to  become  necrotic  and  to  disintegrate.  Cavi- 
ties of  varying  size,  containing  disintegrated  tissue,  fat  and  choles- 
terol crystals,  develop  in  the  newly  formed  tissue  into  what  have 
been  designated  atheromatous  cysts.  These  cysts  may  extend 
toward  the  lumen  of  the  vessel,  opening  into  which  they  may  give 
rise  to  emboli  or  form  rough  ulcers  (often  with  undermined  edges) 
upon  which  thrombi  may  form.  In  the  newly  formed  tissue  of  the 
intima,  as  well  as  in  the  necrotic  foci,  and  in  the  detritus  of  the 
cysts,  calcification  may  occur.  Fatty  degeneration,  atrophy  and 
calcification  may  occur  in  the  muscularis  and  adventitia  of  the 
involved  vessels. 

Symptoms. — These  general  arteriosclerotic  changes  give  rise  to 
symptoms  which  are  attributed  by  the  patient  to  the  stomach 
and  some  primary  disorder  of  digestion.  The  patient  can  never 
be  fully  convinced  but  that  if  his  stomach  were  in  good  condition 
he  would  be  well  again.  Among  the  subjective  symptoms  are  a 
feeling  of  fulness  in  the  epigastrium,  pain  under  the  ensiform  car- 
tilage and  down  the  left  arm,  gaseous  eructations,  and  extreme 
nervousness  and  anxiety.  There  is,  as  a  rule,  immediate  relief 
on  belching.  These  are  the  leading  symptoms  which  were  com- 
plained of  by  any  number  of  patients,  and  which  subsided  after 
appropriate  treatment  directed  to  the  vascular  system.  The 
34 


530         ARTERIOSCLEROSIS— S  Y  PHI  LIS— TUBERCULOSIS 

digestive  disturbances  are  secondary  to  primary  changes  in  the 
arterial  system.  In  fact,  not  only  the  stomach  but  the  whole 
intestinal  tract  is  affected  by  the  changes.  Sclerosis  of  the  intes- 
tinal bloodvessels  in  many  cases  does  not  produce  any  subjective 
or  objective  symptoms.  Sometimes,  however,  mild  or  severe 
disturbances  of  the  bowels  may  be  excited  by  an  extensive  sclerosis 
of  the  abdominal  vascular  apparatus.  Obstinate  flatulence  and 
derangement  of  absorption  may  often  be  found  to  be  due  to  cir- 
culatory disturbances  in  the  abdominal  region  in  consequence  of 
sclerosis  of  the  arteries.  The  violent  and  excruciatingly  painful 
attacks  of  angina  abdominalis  develop  as  a  result  of  arteriosclerosis, 
just  as  angina  pectoris  is  induced  by  sclerosis  of  the  coronary 
arteries.  The  occlusion,  by  sclerosis,  of  certain  branches  of  the 
mesenteric  artery  may  give  rise  to  grave  abdominal  disturbance. 
This  may  be  the  cause  of  intestinal  ulcers,  necroses,  and  severe 
hemorrhages.  Only  within  recent  years  has  it  been  recognized 
that  sclerosis  of  the  abdominal  arteries  may  cause  distressing 
abdominal  symptoms,  an  abdominal  analogue  to  angina  pectoris. 
The  syndrome  has  been  called  by  various  writers  abdominal  apo- 
plexy, intra-abdominal  intermittent  claudication,  intestinal  mio- 
pragia,  and  intermittent  ischemic  dysperistalsis.  The  intestinal 
crises  may  coincide  or  alternate  with  similar  disturbances  in  the 
stomach  from  similar  arteriosclerotic  lesions. 

Diagnosis. — In  his  diagnosis  the  physician  should  not  be  led 
astray  by  the  complaints  of  his  patient  as  to  indigestion,  pain  in 
the  stomach,  distention  and  belching,  but  should  make  a  careful 
search  for  the  underlying  cause  of  the  digestive  disturbances. 

In  patients  past  middle  life  who  complain  of  pain  in  the  stomach, 
distention  after  eating  if  they  attempt  any  physical  exertion,  and 
dyspnea,  relieved  by  belching  of  gas — especially  when  nocturnal 
seizures,  accompanied  by  distention,  heart  disturbances,  dyspnea, 
and  great  anxiety,  are  prominent  symptoms — a  careful  examina- 
tion of  the  vascular  system  will,  as  a  rule,  reveal  the  real  cause  of 
the  condition.  Such  examination  usually  shows  a  heart  somewhat 
enlarged,  an  aortic  second  sound  sharp  and  snapping,  a  murmur 
over  the  aortic  area  and  rough  sounds  over  the  aorta  itself,  pulsa- 
tion in  the  episternal  notch,  attacks  of  pain  over  the  precordial 
region  radiating  to  the  arm,  marked  tenderness  over  the  abdominal 
aorta  down  to  the  navel,  urine  perhaps  increased  in  amount  or 
containing  albumin  in  small  quantity,  or  both  increased  and  albu- 
minous. An  important  sign  is  the  high  blood-pressure,  which  is 
always  suggestive.  All  these  point  unmistakably  to  the  circulatory 
system  as  the  real  cause  of  the  trouble. 

Treatment. — The  treatment  primarily  must  be  directed  toward 
the  general  arteriosclerosis.  Improvement  is  sought  by  various 
measures  that  are  well  known,  such  as  lactovegetable  diet,  hydro- 
therapy, balneotherapy,   gymnastics,  electricity,  and  medication. 


ARTERIOSCLEROSIS  531 

The  diet  should  be  plain,  nutritious,  and  easily  digestible.  The 
evening  meal  should  be  limited  in  size,  to  minimize  the  formation 
of  gas.  Alcohol,  tobacco,  tea  and  coffee  should  be  interdicted  in 
arteriosclerosis,  or  restricted  to  a  minimum.  Moderation  in  eat- 
ing and  drinking  is  essential  to  the  arrest  of  the  pathologic  process 
going  on  in  the  arteries.  Animal  foods  should  be  restricted,  for 
the  digestion  of  these  foods  develops  substances  that  add  to  the 
abnormal  conditions  already  prevailing  in  the  body  (see  page  422). 

Bathing,  fresh  air,  moderate  exercise,  and  attention  to  the  bowels 
should  enter  into  the  hygienic  treatment.  Intense  excitement 
should  be  avoided.  Many  patients  require  absolute  physical  and 
mental  rest,  especially  as  they  enter  the  stage  of  myocardial  inca- 
pacity. By  proper  clothing  the  peripheral  circulation  should  be 
protected  from  sudden  changes  of  temperature. 

Of  medicinal  agents  for  the  treatment  of  arteriosclerosis  pro- 
ducing gastro-intestinal  symptoms,  sodiosalicylate  of  theobromin 
in  doses  of  0.5  to  1  Gm.  (8  to  15  grains)  three  times  a  day  is  recom- 
mended. I  have  found  this  drug  so  satisfactory  in  bringing  about 
an  amelioration  of  symptoms  that  I  have  used  it  as  an  aid  to  diag- 
nosis in  doubtful  cases.  Its  effects  depend  on  its  powerful  action 
in  overcoming  the  vascular  spasm  and  dilating  the  arterioles  so 
that  they  allow  a  greater  flow  of  blood  to  the  sclerosed  areas. 
It  has  been  suggested  that  sodiosalicylate  of  theobromin  may 
neutralize  the  effect  of  some  toxic  agent  which  tends  to  irritate 
the  vasomotor  centers  and  cause  contraction.  Whatever  the  exact 
mode  of  action,  its  effects  are  very  satisfactory,  and  its  use  may  be 
continued  for  one  or  two  weeks  or  even  longer  without  harm.  The 
effect  may  then  be  maintained  by  the  use  of  tincture  of  strophan- 
thus,  5  to  8  drops  three  times  a  day.  Strophanthus  has  been 
observed  to  act  so  much  like  sodiosalicylate  of  theobromin  that 
it  is  used  in  place  of  the  latter  in  some  cases  in  which  expense  is  a 
great  consideration.  Erythrol  tetranitrate  lowers  blood-pressure 
and  maintains  its  vasodilator  effect  for  a  longer  period  of  time  than 
other  preparations  of  the  same  class.  Its  influence  upon  the  blood- 
vessels is  manifest  in  fifteen  to  twenty  minutes  after  the  dose  is 
administered  and  persists  for  three  or  four  hours.  The  dose  is 
0.02  to  0.06  Gm.  (§  to  1  grain).  Variation  in  the  amount  and 
frequency  of  the  dose  is  regulated  by. the  demands  of  the  case  and 
the  effect  on  the  patient.  The  nitrites  act  on  the  preganglionic 
endings  of  the  sympathetic  nerve  fibers,  which  are  the  inhibitory 
nerves  of  the  intestine. 

Papaverin  hydrochlorid  is  a  powerful  dilator  of  the  coronary 
artery  and  lowers  general  blood-pressure  by  directly  dilating  the 
bloodvessels,  especially  the  splanchnic  and  peripheral  vessels.  In 
doses  of  0.03  Gm.  (J  grain)  it  relaxes  muscles  of  the  cardia,  pyloric 
sphincter,  and  intestine.  Benzyl  benzoate  has  been  used  with  great 
benefit  in  abdominal  angina.    It  is  a  powerful  vasodilator  with  no 


532         ARTERIOSCLEROSIS— SYPHILIS— TUBERCULOSIS 

depressing  effect  upon  the  heart.  Its  action  is  due  to  the  inhibitory 
and  tonus-lowering  or  spasm-relaxing  action  of  the  benzyl  radical 
on  smooth  muscle  (see  page  276). 

In  prescribing  the  iodids  in  arteriosclerosis,  the  continued  good 
effects  of  this  medication  are  to  be  obtained  only  by  gradually 
increasing  the  dosage  until  the  sluggish  live  cells  are  sufficiently 
stimulated  and  enough  degenerated  cells  destroyed  to  insure  the 
restitution  of  function  in  the  tissues.  The  prolonged  administra- 
tion of  small  doses  fails  to  accomplish  permanently  favorable 
results;  but  large  and  progressively  increasing  doses  produce 
strikingly  good  results,  in  early  cases  particularly.  In  the  use  of 
potassium  iodid  the  patient  is  to  be  started  with  a  0.6-Gm.  (10- 
grain)  dose  three  times  daily,  which  should  be  daily  increased 
until  4  to  4.6  Gm.  (60  to  70  grains)  is  given  each  day.  Iodism 
can  be  prevented  by  the  careful  exclusion  of  acids  from  the  diet, 
and  by  neutralization  of  the  acid  contents  of  the  stomach  by  means 
of  any  agreeable  alkali.  In  this  connection  it  should  be  stated  that 
potassium  iodid  reduces  the  viscosity  of  the  blood  and  in  that  way 
assists  in  the  relief  of  blood-pressure  and  in  invigoration  of  the 
arterial  tissues. 

Thyroid  extract  has  been  administered  in  arteriosclerosis,  with 
favorable  results,  due  to  its  power  to  control  high  arterial  pressure. 

In  the  endeavor  to  combat  arteriosclerosis  by  promoting  vascular 
metabolism,  strengthening  the  vasomotor  nerves,  and  reducing 
the  tension  of  the  vessels,  Trunecek  resorted  to  the  hypodermic 
administration  of  the  inorganic  blood  salts.  His  results  have  been 
confirmed  by  Tessier,  Levy,  Merlken,  Zanoni  and  others;  the 
serum  acts  on  the  calcium  phosphate,  relieves  dyspnea  by  increas- 
ing the  alkalinity  of  the  blood,  has  a  direct  effect  on  the  heart 
and  the  yascular  endothelium,  and  stimulates  the  vasomotor  sys- 
tem. Levy  has  found  that,  given  by  mouth,  the  salts  have  the 
same  effect  as  when  administered  hypodermically.  Under  the 
trade  name  antisclerosin  a  combination  consisting  of  these  blood 
salts  is  available.     Each  dose  (two  tablets)  contains: 

Gm.  or  Cc. 

1$. — Sodii  chloridi 0  8  gr.  xij 

Sodii  sulphatis   .......  0  08  gr.  ij 

Magnesii  phosphatis, 

Sodii  carbonatis  exsiccati  .      .      .   aa  0  03  gr.  ss 

Sodii  phosphatis, 

Calcii  glycerophosphatis     .      .      .  aa  0  025  gr.  f 

This  represents  at  least  15  Cc.  of  Trunecek' s  serum,  and  equals 
the  saline  contents  of  about  150  Cc.  of  blood  serum. 

Though  certain  cases  are  incurable,  antisclerosin  will  often  relieve 
the  subjective  and  objective  symptoms  in  even  severe  cases.  Its 
chief  field  of  usefulness  is  as  a  prophylactic. 


SYPHILIS  533 


SYPHILIS. 


The  occurrence  of  syphilis  in  the  stomach  is  not  as  infrequent 
ns  we  have  been  led  to  believe.  Statements  from  various  sources 
tend  to  show  that  about  one  out  of  seventy-five  of  our  gastric 
cases  is  syphilitic.  All  the  cases  so  far  observed  have  occurred 
during  the  tertiary  stage  of  the  disease.  Gastric  syphilis  appears 
in  three  forms — (1)  specific  ulcers  of  the  stomach;  (2)  specific 
tumors;  (3)  specific  stenosis  of  the  pylorus.  The  syphilitic  ulcer 
is  the  most  frequent  manifestation  of  syphilis  affecting  the  stomach; 
it  may  develop  as  a  result  of  disturbances  in  the  circulation  affect- 
ing circumscribed  areas  of  the  gastric  mucous  membrane,  and  having 
as  its  primary  cause  a  specific  endarteritis.  Ulcers  may  also  arise 
from  the  disintegration  of  gummata  in  the  submucous  coat  of  the 
stomach.  The  gummatous  ulcer  develops  in  the  submucosa,  while 
that  caused  by  specific  endarteritis  is  essentially  an  ulcer  of  the 
mucosa;  neither  differs  in  any  way  from  the  ordinary  round  ulcer, 
except  that  the  specific  ulcer  is  much  less  responsive  to  treatment. 
In  syphilitic  ulcer  we  find  subacidity,  rather  than  hyperacidity  as 
in  round  ulcer.  In  specific  stenosis  of  the  pylorus  the  whole  stom- 
ach may  become  cirrhotic,  due  to  an  increase  of  connective  tissue. 
Many  cases  of  that  rare  disease  known  as  linitis  plastica  (gastric 
cirrhosis)  have  been  supposed  to  be  caused  by  syphilis,  but  we  now 
know  they  are  caused  by  carcinoma  (see  page  546) . 

Diagnosis. — It  is  a  very  difficult  matter  to  make  a  diagnosis  of 
syphilitic  ulcer,  and  the  clinician  must  rely  upon  the  known  pres- 
ence of  syphilitic  infection  in  order  to  be  at  all  certain  that  the 
gastric  ulcer  is  of  luetic  origin.  The  presence  or  absence  of  the 
Treponema  pallidum  (Spirochseta  pallida)  is  not  to  be  depended 
upon  in  determining  the  presence  or  absence  of  ulcer  of  syphilitic 
origin.  These  microorganisms  are  often  absent  in  cases  of  un- 
doubted syphilis;  on  the  other  hand,  Koch,  using  the  Levaditi 
stain,  found,  in  cases  of  undoubted  carcinoma  of  the  lung,  organ- 
isms of  the  typical  appearance  of  the  Treponema  pallidum.  A 
positive  Wassermann  reaction  materially  assists  in  the  diagnosis. 
The  luetin  test  of  Xoguchi,  involving  a  cutaneous  reaction  after 
injecting  into  the  superficial  layers  of  the  skin  dead  cultures  of 
Treponema  pallidum  is  usually  positive  in  tertiary  syphilis;  but 
the  test  cannot  be  depended  upon  in  the  primary  and  secondary 
stages.  Under  specific  treatment  during  the  secondary  stage,  espe- 
cially after  the  administration  of  arsphenamine,  a  positive  luetin 
reaction  can  be  obtained.  The  test  is  valuable  in  obscure  tertiary 
manifestations,  where  the  Wassermann  reaction  often  fails.  The 
disappearance  of  the  luetin  reaction,  according  to  Xoguchi,  may 
mean  that  the  patient  has  fully  recovered  from  the  disease. 
Syphilitic  ulceration  of  the  stomach  should  be  distinguished  clin- 
ically from  carcinoma  and  the  gastric  crises  of  locomotor  ataxia. 


534         ARTERIOSCLEROSIS— SYPHILIS— TUBERCULOSIS 

The  differentiation  between  syphilitic  ulcer  and  other  conditions 
producing  dyspeptic  symptoms  may  be  further  made  by  a  course 
of  antisyphilitic  remedies,  such  as  potassium  iodid,  which  will 
usually  ameliorate  syphilitic  symptoms  while  the  same  treatment 
would  have  the  reverse  effect  upon  ordinary  cases  of  gastritis. 

Garel's  diagnostic  sign  is  prolonged  and  painful  dysphagia. 
There  may  be  no  other  symptom  suggesting  the  possibility  of 
S3^philis.  In  all  cases  of  prolonged  dysphagia  referred  to  the 
pharynx,  a  Wassermann  test  should  be  made. 

Treatment.' — The  treatment  of  syphilis  of  the  stomach  consists 
in  the  methods  and  agents  employed  in  cases  of  gastric  ulcer  and 
gastric  hemorrhage,  together  with  such  specific  remedies  as  arsphen- 
amine,  mercury,  and  the  iodid  s,  the  latter  being  tolerated  well  by 
the  luetic  stomach.     (See  Chapters  XXV  and  XXVI.) 

Arsphenamine  (saharsan)  is  a  yellowish  crystalline  arsenical  com- 
pound, not  unlike  iodoform  in  appearance,  and  must  be  kept  in 
hermetically  sealed  ampoules,  for  it  becomes  very  toxic  when 
exposed  to  the  air.  For  administration  it  must  be  handled  with 
the  greatest  care  and  every  detail  in  the  prescribed  technic  carried 
out.  The  dose  (for  intramuscular  or  intravenous  injection)  is 
0.3  to  0.6  Gm.  (5  to  10  grains). 

Neoarsphenamine  (neosalvarsan). — Ehrlich  has  given  us  an  im- 
proved salvarsan  (neosalvarsan),  now  known  as  neoarsphenamine. 
It  is  a  fine  powder,  resembling  salvarsan,  but  somewhat  more  yellow- 
ish in  color  and  turning  reddish  on  exposure  to  the  air.  It  dissolves 
readily  in  water,  which  becomes  yellow  without  stirring.  The 
solution  is  neutral  in  reaction,  which  eliminates  the  use  of  sodium 
hydroxid  for  alkalinizing  purposes.  Neoarsphenamine  can  be  given 
both  intramuscularly  and  intravenously  and  in  larger  doses  than 
arsphenamine.  On  account  of  its  non-irritating  character  ft  can  be 
given  with  greater  safety  by  simply  dissolving  it  in  water.  Since 
it  can  be  so  easily  manipulated,  its  value  is  obvious.  The  dose  of 
neoarsphenamine  is  0.9  Gm.  (14  grains)  for  men  and  0.75  Gm.  (12 
grains)  for  women. 

Ehrlich  has  also  introduced  sodium-salvarsan  (No.  1206A), 
which  is  supposed  to  combine  the  advantages  of  the  two  earlier 
preparations.  It  is  a  fine  golden-yellow  powder,  readily  soluble  in 
water.  It  contains  the  same  proportion  of  arsenic  as  arsphenamine 
and  neoarsphenamine.  The  dose  ranges  from  0.6  to  1  Gm.,  without 
any  discomfort  from  the  larger  doses.  The  drug  has  been  found 
to  be  absolutely  non-toxic,  and  the  injections  do  not  produce  the 
slightest  reaction.  It  can  therefore  be  given  in  cases  of  syphilis 
associated  with  apoplexy,  diabetes,  nephritis  or  other  diseases. 
Sodium-salvarsan  is  really  old  salvarsan  so  modified  as  to  be  as 
easily  given  as  neosalvarsan  (neoarsphenamine). 

A  large  number  of  patients  have  been  successfully  treated  with 
these  preparations,  which  have  been  used  in  all  stages  of  syphilis, 


SYPHILIS  535 

from  the  primary  chancre  to  the  deep  specific  lesions  of  the  central 
nervous  system.  They  possess  apparently  the  peculiar  property 
of  killing  and  exterminating  the  Treponema  pallidum  (Spirochseta 
pallida)  wherever  it  is  to  be  found  in  the  body.  They  are  known 
to  cure  syphilis  in  all  three  stages,  particularly  when  combined 
with  a  course  of  mercury.  The  first  effect  is  manifest  in  modifi- 
cation of  the  appearance  of  syphilides,  mucous  patches,  gummata, 
and  chancre.  The  shooting  pains,  the  girdle  sensation,  and  the 
tabetic  crises  are  relieved  almost  immediately.  But  a  single  dose 
of  arsphenamine  will  not  eradicate  the  disease.  In  the  initial 
stage  of  the  infection,  arsphenamine  is  more  effective  than  mercury; 
and  when  mercury  and  the  iodids  have  failed,  arsphenamine  is 
often  beneficial.  From  the  observations  of  many  clinicians,  how- 
ever, it  may  be  fairly  concluded  that  the  best  results  are  obtained 
by  giving  mercury  as  well  as  arsphenamine. 

The  intravenous  administration  of  bichlorid  of  mercury,  in  doses 
of  0.02  Gm.  (^  grain)  dissolved  in  10  Cc.  (2£  drams)  of  freshly 
distilled  water,  is  of  great  benefit.  To  avoid  as  far  as  possible  the 
danger  of  causing  phlebitis  by  placing  mercury  in  the  vein,  the 
injection  should  be  performed  very  slowly,  and  a  new  vein  chosen 
for  each  consecutive  injection.  The  mercury  will  be  much  less 
apt  to  injure  the  vein  if  a  syringe  with  a  capacity  of  about  20 
Cc.  be  used,  so  that  the  mercurial  solution  in  the  syringe  may  be 
diluted  with  the  patient's  blood  before  being  injected  into  the  vein. 
After  the  needle  has  entered  the  vein,  by  traction  on  the  piston  the 
physician  should  withdraw  sufficient  blood  to  fill  the  barrel  of  the 
syringe,  when,  without  removing  the  needle,  the  mercurialized 
blood  should  be  slowly  introduced.  The  injections  may  be  given 
at  intervals  of  four  to  six  days  and  continued  until  the  Wassermann 
reaction  is  negative. 

Syphilitic  stenosis  of  the  pylorus  is  an  exceedingly  rare  condition, 
which  may  be  due  to  cicatrices  of  syphilitic  ulcers  or  tumors  and 
gummatous  infiltration  in  the  region  of  the  pylorus.  The  treatment 
for  this  condition  is  the  same  as  for  motor  disturbances  (see  Chapter 
XXIV). 

General  Treatment. — Patients  suffering  from  syphilitic  disease 
of  the  stomach  should  be  kept  at  rest,  preferably  in  bed.  The 
food  should  be  of  a  simple,  unirritating  kind,  its  precise  character 
depending  upon  the  severity  of  the  symptoms.  In  very  severe 
cases  it  may  be  necessary  to  resort  to  rectal  alimentation.  In 
any  case  it  is  advisable  to  inaugurate  the  dietetic  treatment  by 
the  use  of  milk.  As  the  condition  of  the  patient  improves,  the 
quantity  and  variety  of  the  food  may  be  slowly  increased,  and 
jellies  flavored  with  lemon  and  sweetened,  junket,  eggs  lightly 
cooked  or  beaten  up  with  milk,  custards,  or  tapioca  pudding  may 
be  permitted.    This  regimen  may  be  followed  later  by  bread  and 


536  ARTERIOSCLEROSIS— SYPHILIS— TUBERCULOSIS 

butter,  fish,  chicken,  rabbit,  or  veal.     No  meat  should  be  allowed 
for  at  least  six  months. 

The  bowels  should  be  carefully  regulated,  and  for  the  control  of 
constipation  resort  should  be  had  to  saline  cathartics. 

TUBERCULOSIS. 

Gastric  tuberculosis  is  a  very  rare  condition,  and  when  present  is 
usually  secondary  to  or  associated  with  tuberculosis  of  other  organs. 

Forms.- — Three  forms  of  tuberculosis  of  the  stomach  have  been 
recognized,  namely:  (1)  Miliary  tuberculosis — always  secondary 
to  general  miliary  tuberculosis;  it  cannot  be  diagnosticated,  and  is 
therefore  not  subject  to  treatment.  (2)  Tuberculous  ulcer.  This 
occasionally  produces  disturbances  similar  to  those  produced  by 
peptic  ulcer;  hemorrhages  are  not  infrequent,  and  perforation  is 
more  likely  to  occur  than  with  peptic  ulcer.  Tuberculous  ulcer 
has  been  attributed  to  the  swallowing  of  tuberculous  sputum.  It 
may  also  result  from  infection  through  the  blood  and  lymph  routes. 
The  treatment  is  that  of  peptic  ulcer.  (3)  Tuberculous  granula- 
tion tumors — located  on  the  pylorus  or  in  the  region  of  the  pylorus. 
The  symptoms  resemble  those  of  gastric  carcinoma,  and  the  treat- 
ment is  the  same  as  for  the  latter.  In  tuberculous  stenosis  of  the 
pylorus,  success  has  followed  resection. 

Treatment. — The  treatment  of  tuberculosis  of  the  stomach  is 
the  treatment  of  tuberculosis  localized  elsewhere  in  the  body. 


CHAPTER  XXIX. 

TUMORS  OF  THE  STOMACH. 

Carcinoma;  Sarcoma;  Fibroma;  Fibromyoma;  Lipoma;  Adenoma; 
Papilloma;  Polypi;  Hernia  Epigastrica. 

CARCINOMA. 

Gastric  carcinoma  consists  of  a  malignant  new-growth  or 
tumor  made  up  principally  of  epithelial  cells  and  developing  in 
the  epithelial  tissue  of  the  stomach. 

Etiology. — Incidence. — Of  all  the  viscera  of  the  body,  the  stomach 
is  most  frequently  the  seat  of  carcinoma.  Of  the  total  number  of 
carcinoma  cases  reported,  from  40  to  45  per  cent,  are  said  to  be 
carcinoma  of  the  stomach.  It  occurs  more  frequently  in  males  than 
in  females.  According  to  Wyss  the  death-rate  from  gastric  car- 
cinoma is  nearly  2  per  cent,  of  the  total  mortality;  Bryant  states 
that  in  New  York  City  for  the  ten  years  immediately  preceding 
1896  it  was  2.17  per  cent,  of  the  total  mortality.  In  the  United 
States  census  of  1912  we  find  46,534  deaths  from  carcinoma;  of 
these,  18,517  were  of  the  stomach  (39.75  per  cent.).  The  frequency 
of  this  disease  varies  in  different  countries.  There  are  certain 
regions  in  which  it  rarely  occurs.  Griesinger  states  that  he  has 
never  seen  a  case  of  carcinoma  of  the  stomach  in  Egypt,  while 
Heinemann  reports  that  he  saw  only  one  case  in  Vera  Cruz  during 
a  period  of  six  years.  When  we  consider  the  advances  that  have 
been  made  in  medical  science  in  the  way  of  refinement  of  diag- 
nosis, it  is  evident  that  carcinoma  is  more  frequently  discovered 
and  differentiated  from  non-malignant  growths  than  was  formerly 
the  case.  This  of  itself  would  account,  in  a  measure,  for  the 
apparent  increase  in  the  prevalence  of  the  disease. 

In  the  development  of  carcinoma  a  certain  individual  predis- 
position is  necessary,  which  may  be  either  congenital  or  acquired, 
although  we  do  not  know  exactly  the  nature  of  this  predisposition.1 
Certain  substances  which  would  inhibit  or  defend  the  body  against 
the  formation  of  carcinoma  may  be  absent.  It  has  been  shown 
that  immunity  to  carcinoma  bears  a  certain  relation  to  the  number 
of  white  lymph  corpuscles  present  in  the  blood.  The  number  of 
these  may  be  increased  in  an  active  manner  by  the  body  itself  in 
resisting  the  development  of  the  carcinoma,  or  passively  stimulated 
by  the  injection  of  lymph  tissues.     There  may  be  a  local  initia- 

1  Czerny,  Munchener  medizinsche  Wochenschrift,  April  1,  1913. 


538  TUMORS  OF  THE  STOMACH 

tion  of  carcinoma,  such  as  trauma,  injury,  inflammation,  a  scar, 
or  some  congenital  malformation.  Or,  possibly,  there  is  a  car- 
cinoma organism,  belonging  to  the  group  of  hitherto  unknown 
ultramicroscopic  organisms,  and  which  is  brought  to  the  human 
subject  by  an  intermediate  carrier.  Whether  this  carrier  is  the 
bed-bug  or  other  blood-sucking  parasite,  or  one  of  the  family  of 
the  small  pin-worms  carried  by  cockroaches,  is  not  certain.  Ob- 
servations seem  to  point  to  a  certain  infection,  not  direct,  but 
indirect  through  parasites.  In  all  infectious  diseases  the  virulence 
of  the  exciting  agent  is  of  great  importance,  for  the  healthy  body 
has  a  certain  power  of  resistance  toward  pathogenic  agents  in 
general. 

Among  predisposing  if  not  strictly  etiologic  factors,  gastric  ulcer, 
the  cicatrix  of  an  ulcer,  and  chronic  gastritis  may  be  mentioned. 
Some  surgeons  attribute  all  gastric  carcinomata  to  a  previous 
ulcer  of  the  stomach.  In  a  study  by  Friedenwald1  of  1000  cases 
of  carcinoma  in  which  careful  records  had  been  kept,  there  was  a 
history  of  some  previous  digestive  trouble  in  232  cases  (23  per 
cent.).  Of  the  232  cases  109  had  had  slight  attacks  of  indigestion 
for  a  period  of  five  years.  Of  the  remaining  123  cases,  32  had  had 
chronic  indigestion  more  or  less  all  their  lives,  mainly  (in  29  of 
the  32)  during  the  last  five  years  preceding  the  present  illness. 
Seventy-three  cases  gave  a  definite  history  of  former  gastric  ulcer. 
It  is  therefore  evident  that  of  the  1000  cases  but  23  per  cent,  pre- 
sented a  history  of  any  previous  digestive  disturbance  whatever, 
even  in  the  slightest  degree,  and  that  but  7.3  per  cent,  gave  a 
direct  history  of  ulcer.  If,  therefore,  all  of  the  former  digestive 
disturbances  be  considered  as  due  to  ulcer,  the  formation  of  gastric 
carcinoma  from  ulcer  could  not  have  taken  place  in  more  than  23 
per  cent.;  if  all  of  the  cases  with  slight  digestive  disturbances  be 
disregarded  this  percentage  is  reduced  to  12.3  per  cent. 

From  a  study  of  445  pathologic  sections  of  gastric  carcinoma, 
339  of  which  were  resected  by  the  surgeon  and  46  removed  at 
necropsy,  Wilson  concludes  that  "practically  all  carcinomata 
develop  on  the  site  of  a  previous  ulcerative  lesion  of  the  gastric 
mucosa."2  This  report  is  not  in  accord  with  our  clinical  experi- 
ence. Albert  Kocher3  states  that  he  has  personally  examined  the 
Mayos'  specimens,  and  is  convinced  that  much  of  what  they 
labeled  cancerous  degeneration  of  ulcers  was  in  reality  merely 
atypical  proliferation  of  epithelium. 

Age.- — Regarding  the  age  at  which  gastric  carcinoma  occurs 
most  frequently,  Brinton  has  collected  some  interesting  data.     In 

1  American  Journal  of  the  Medical  Sciences,  November,  1914,  p.  666. 

2  Wilson  and  McDowell,  American  Journal  of  the  Medical  Sciences,  December, 
1914. 

3  Chronic  and  Duodenal  Ulcer,  Correspondenz-Blatt  fur  Schweizer  Aerzte,  Basel, 
May  10,  1919,  No.  19. 


CARCINOMA  539 

600  cases  the  year  of  death  averaged  fifty — two-sevenths  of  these 
between  fifty  and  sixty.  This  writer  places  the  maximum  lia- 
bility between  sixty  and  seventy.  Under  twenty,  the  whole  risk 
is  less  than  one-fiftieth  of  what  it  is  between  twenty  and  thirty. 
Lebert  gives  us  the  following  figures  as  to  the  age  at  which  car- 
cinoma of  the  stomach  occurs:  Under  thirty  years,  1  per  cent.; 
thirty  to  forty  years,  17.6  per  cent.;  forty  to  sixty,  60.7  per  cent.; 
sixty  to  seventy,  16.3  per  cent.;  above  seventy,  4.4  per  cent. 

Heredity. — The  influence  of  heredity  as  a  predisposing  cause  of 
carcinoma  of  the  stomach  is  still  an  open  question.  The  occur- 
rence of  carcinoma  in  one  or  more  of  the  offspring  of  carcinomatous 
parents  has  been  noted,  but  not  with  marked  frequency.  Car- 
cinoma has  been  known  to  attack  persons  whose  health  up  to  the 
time  of  the  attack  had  been  remarkably  good. 

Pathology. — Gastric  carcinoma  consists  of  atypical  epithelial 
proliferation  having  its  starting  point  in  the  glandular  cells  and  the 
epithelial  lining  of  the  secretory  ducts.  It  develops  into  a  tumor 
of  varying  size,  sometimes  attaining  such  dimensions  as  to  occlude 
the  lumen  of  the  stomach.  Carcinoma  occasionally  consists  of 
more  or  less  flat  granulations  and  excrescences.  In  many  instances 
there  is  a  tendency  to  superficial  and  sometimes  to  deep  ulceration 
and  necrosis,  infiltrating  the  walls  of  the  organ  until  it  becomes  a 
cavity  enclosed  by  carcinomatous  tissue.  As  this  process  involves 
the  bloodvessels,  hemorrhage  occurs. 

Gastric  carcinoma  forms  metastases  by  way  of  the  lymphatics, 
as  a  rule.  In  some  instances,  especially  in  the  medullary  and  scir- 
rhous types,  this  occurs  early.  The  glands  draining  the  gastric  area 
rapidly  become  involved,  and  metastatic  nodules  appear  in  the 
omentum  and  peritoneum,  which  in  some  cases  is  so  massively 
infiltrated  that  dissection  is  difficult.  Not  infrequently  so-called 
"precocious  metastases"  appear  in  the  skin,  in  the  bones,  and  in 
other  distant  organs.  In  very  many  instances  growth  of  the  tumor 
takes  place  by  infiltration  so  that  wide  areas  of  the  stomach  wall 
are  affected  and  become  markedly  thickened  and  inelastic.  In  the 
progress  of  such  growth  bloodvessels  may  be  involved,  and  cells  of 
the  tumor,  set  free  in  the  blood,  are  then  disseminated  to  the  liver, 
lungs,  heart,  and  rectum. 

Carcinomata  differ  widely  not  only  in  gross  and  microscopic 
structure  but  also  in  respect  to  rapidity  of  growth  and  degree  of 
malignancy.  Some  grow  with  alarming  rapidity  (carcinoma  sim- 
plex), while  others  remain  dormant  or  nearly  stationary  for  long 
periods  of  time  (many  adenocarcinomata,  and  the  diffuse  fibro- 
carcinomata) . 

Gastric  carcinoma  is  most  frequently  located  in  the  pyloric 
region  (60  per  cent.),  and  in  such  cases  is  prone  to  bring  about  a 
stenosis  of  the  orifice  and  an  accompanying  dilatation  of  the  stomach 
(see  Chapter  XXIV).     Forty  per  cent,  of  carcinomata  appear  to 


540  TUMORS  OF  THE  STOMACH 

be  equally  divided  between  the  lesser  curvature  (including  the 
cardia)  and  the  greater  curvature.  Diffuse'  cancerous  infiltration 
of  the  stomach  occurs  in  about  6  per  cent,  of  the  total  number  of 
cases. 

Forms. — The  forms  of  gastric  carcinoma,  in  the  order  of  their 
frequency,  are:  Medullary  carcinoma,  adenocarcinoma,  colloid  car- 
cinoma, and  scirrhous  carcinoma. 

Medullary  Carcinoma  {Including  Carcinoma  Simplex.) — Medul- 
lary carcinomata  are  of  two  gross  forms :  one  consisting  of  soft, 
rounded,  large  but  circumscribed  tumors,  appearing  chiefly  in 
the  cardia  and  fundus;  the  other  a  diffuse  growth,  appearing  most 
frequently  near  the  pylorus.  The  former  is  the  "most  aggressive 
and  rapidly  progressive  form  of  gastric  carcinoma"  (Ewing).  The 
latter  is  a  type  with  which  perforation  is  most  frequent.  Both  tend 
to  early  metastases,  early  ulcerations,  and  hemorrhage. 

Adenocarcinoma. — The  adenocarcinomata  of  the  stomach  are 
relatively  benign.  For  the  most  part  they  form  circumscribed 
polypoid  or  f ungating,  and  eventually  ulcerating,  masses.  They 
appear  near  the  pylorus,  in  which  case  ulceration  takes  place  earlier, 
or  on  the  curvatures,  where  they  reach  a  larger  size.  Occasionally 
they  seem  to  be  the  result  of  carcinomatous  transformation  of 
adenomatous  polyps,  and  in  some  such  instances  there  are  no 
prominent  gastric  symptoms  and  no  invasion  of  nodes. 

Gelatinous  or  Colloid  Carcinoma. — lhe  gelatinous  or  colloid 
carcinomata  result  from  colloid  or  mucoid  transformation  of  the 
cells  of  malignant  growths.  If  it  be  that  this  change  appears  in 
medullary  cancers,  then  other  changes  also  occur,  for  in  the  colloid 
type  invasion  of  the  lymph  nodes  is  later,  growth  by  extension  more 
frequent,  and  diffuse  infiltration  more  marked  than  in  the  medullary 
form.    The  peritoneum  is  very  frequently  and  extensively  involved. 

Scirrhous  Carcinoma. — It  is  the  relatively  large  amount  of  fibrous 
tissue  as  compared  with  the  epithelial  tissue  which  gives  the  firmness 
to  the  growths  called  scirrhous.  These  are  very  firm,  sometimes 
almost  cartilaginous  in  appearance  and  texture.  In  the  somewhat 
pearly  substance  may  be  seen  small  points  or  lines  of  a  yellowish 
or  reddish  hue,  which  represent  the  epithelial  tissue  that  is  under- 
going fatty  metamorphosis.  Such  growths  are  slowly  progressive. 
Ulceration  is  late,  as  a  rule.  Because  of  the  character  of  the  growth 
and  the  frequency  of  its  localization  at  or  near  the  pylorus,  pyloric 
stenosis  is  a  common  result.  But  while  it  is  ordinarily  located  in  the 
pyloric  region,  it  may  involve  a  large  portion  of  the  stomach  or 
even  the  whole  organ  (sclerosing  pyloric  and  diffuse  fibrocarcinoma; 
linitis  plastica;  see  page  546).  While  ulceration  occurs  late,  super- 
ficial erosions  of  large  extent  may  appear  early.  The  lymph  nodes 
are  involved  regularly  and  early,  and  the  metastatic  nodules  are 
prone  to  become  large  and  are  always  more  cellular  than  the  orig- 
inal growth.  0 


CARCINOMA  5  1 1 

Ulcerocarcinoma. — Because  of  the  frequency  with  which  malig- 
nant epithelial  changes  occur  in  connection  with  chronic  gastric 
ulcers,  and  because  of  the  rather  typical  clinical  history  that  is 
associated  with  such  tumors,  it  is  the  custom  of  some  writers  to  use 
the  term  "ulcerocarcinoma"  in  describing  these  cases. 

Complications. — The  portion  of  the  gastric  mucous  membrane 
that  is  not  directly  involved  in  the  carcinomatous  process  may 
function  in  a  perfectly  normal  manner,  especially  during  the 
initial  stage  of  the  disease.  This,  however,  does  not  continue 
for  any  great  length  of  time,  owing  to  the  progressive  atrophic 
changes  which  take  place  in  the  gastric  mucous  membrane.  In 
cases  of  gastric  carcinoma  complicated  with  pyloric  stenosis  and 
stagnation,  a  frequent  feature  is  chronic  gastritis  with  marked 
secretion  of  mucus  and  a  decrease  in  the  secretion  of  gastric  juice. 

Complications  of  gastric  carcinoma  may  consist  of  adhesions  to 
or  rupture  into  neighboring  organs,  such  as  the  intestine,  gall 
bladder,  pancreas,  and  liver.  Perforation  into  the  peritoneal  cav- 
ity is  rarely  met.  Other  rare  complications  are  rupture  into  the 
pleural  cavity,  subphrenic  abscess,  pyopneumothorax,  and  free 
bleeding  from  the  carcinoma  itself  (gastric  hemorrhage). 

Symptoms. — The  earliest  symptoms  of  carcinoma  of  the  stomach 
are  pressure  and  fulness  after  eating.  This  mild  sensation  is 
superseded  sooner  or  later  by  pain  of  varying  intensity;  the  pain 
may  be  felt  in  the  region  of  the  stomach,  directly  in  front  or  to 
the  right  or  left  of  the  median  line,  or  it  may  be  felt  in  the  dorsal 
region.  Pain  is  not  a  constant  symptom,  however;  it  is  often 
absent,  particularly  when  the  carcinoma  is  s'tuated  on  the  lesser 
curvature.  The  patient  is  frequently  annoyed  by  eructations 
due  to  decomposition  of  the  food  mass  within  the  stomach.  Ano- 
rexia is  among  the  early  symptoms,  the  patients  manifesting  a 
distaste  for  meat.  In  a  few  cases  the  normal  appetite  has  been 
known  to  continue  for  a  long  time  after  the  appearance  of  the 
initial  symptoms;  and  in  rare  cases  there  is  a  markedly  increased 
appetite.  As  a  rule  the  patients  complain  of  weakness  and  are 
disinclined  or  unable  to  work.  They  lose  flesh  rapidly.  These 
symptoms  progress  until  nausea  and  vomiting  become  trouble- 
some features.  Vomiting  depends  largely  upon  the  location  of  the 
neoplasm;  carcinoma  of  the  pylorus  is  nearly  always  accompanied 
by  vomiting,  owing  to  stenosis  of  the  pyloric  exit.  In  carcinoma 
of  the  greater  or  lesser  curvature  there  may  be  no  vomiting  at 
any  time  throughout  the  course  of  the  disease.  When  vomiting 
becomes  severe,  great  thirst  is  experienced,  and  a  marked  diminu- 
tion in  the  quantity  of  urine  excreted  is  noted. 

The  inability  to  assimilate  food  results  in  rapid  loss  of  weight. 
This  condition  becomes  so  marked  that  many  patients  die  of 
inanition. 

Statistics  show  that  60  per  cent,  of  the  carcinomata  of  the  stomach 


542  TUMORS  OF  THE  STOMACH 

attack  the  pyloric  region,  20  per  cent,  the  lesser  curvature  and  cardia, 
and  20  per  cent,  the  greater  curvature.  Carcinoma  of  the  pylorus 
seems  to  be  associated  with  hypersecretion,  while  carcinoma  of  the 
lesser  curvature  is  more  often  associated  with  achylia. 

In  carcinoma  of  the  cardia  the  subjective  symptoms  are  most 
insidious.  Difficulty  in  deglutition  is  one  of  the  first  distinct 
signs  confirmatory  of  the  diagnosis;  it  results  from  occlusion 
of  the  lower  end  of  the  esophagus.  The  patient  finds  that  he 
cannot  swallow  solid  foods  with  ease;  he  experiences  a  sensation 
of  the  food  "sticking  fast"  before  it  enters  the  stomach.  Pain 
results  from  the  movement  of  the  food  through  the  stenotic  cardiac 
orifice. 

As  the  disease  progresses  the  patients  acquire  a  characteristic 
cachectic  appearance — loss  of  flesh  and  sallow  complexion.  In 
the  later  stages  of  the  disease  anemia  supervenes;  the  percentage 
of  hemoglobin  and  the  number  of  red  blood-cells  are  much  below 
normal.  The  anemic  condition  may  be  due  to  hemorrhages,  to 
insufficient  nutrition,  or  to  the  effect  of  toxins  from  the  carcinoma. 
Hemolytic  substances  have  been  discovered  in  the  gastric  contents 
of  carcinomatous  patients.  Not  infrequently  there  is  edema  in 
the  region  of  the  ankles. 

Diagnosis.- — Examination  of  the  stomach  in  a  typical  case  of 
gastric  carcinoma  reveals  a  tumor  of  varying  location,  size  and 
shape.  Tumors  of  the  pylorus  are  usually  located  to  the  right  of 
the  median  line;  with  the  stomach  in  the  normal  position  it  is 
impossible  to  palpate  such  tumors,  owing  to  overlapping  by  the 
liver;  when  not  concealed  by  the  liver  they  may  be  felt  below 
the  right  border  of  the  ribs,  protruding  during  deep  inspiration. 
When  the  stomach  has  descended  it  may  be  palpated  at  varying 
distances  below  the  ribs.  Tumors  of  the  lesser  curvature  may 
likewise  be  so  covered  by  the  liver  as  to  render  palpation  impossible. 
The  usual  site  of  tumors  of  the  greater  curvature  and  of  the  fundus 
is  at  the  level  of  the  umbilicus  or  below  it.  These  differ  from 
neoplasms  of  the  pylorus  in  the  absence  of  symptoms  of  obstruction 
produced  by  pyloric  stenosis.  When  the  neoplasms  have  formed 
adhesions  to  neighboring  organs  of  the  abdominal  cavity,  they  are 
found  to  be  immovable  or  only  slightly  movable  on  palpation. 
Motor  insufficiency  supervenes  in  cases  of  carcinoma  of  the  pylorus 
in  proportion  to  the  degree  of  stenosis  present.  The  most  fre- 
quent seat  of  metastasis  is  the  liver,  which,  when  affected,  usually 
shows  marked  enlargement.  When  the  carcinomatous  growth 
has  progressed  for  a  considerable  length  of  time  the  supraclavicular 
glands  of  the  left  side  may  be  enlarged. 

Carcinomata  are  found,  however,  to  vary  in  a  marked  degree 
from  the  type  here  outlined.  The  latent  stage  of  carcinoma  is 
often  prolonged.  The  tumor  may  not  be  discovered;  subacidity 
or  achylia  may  be  diagnosticated  from  an  examination  of  the  gas- 


CARCINOMA  543 

trie  contents,  with  no  further  objective  symptoms  which  would  point 
to  the  presence  of  malignant  growth.  Differing  from  our  typical 
case,  free  hydrochloric  acid  may  be  present  for  a  long  time  after 
the  initiation  of  the  carcinomatous  process,  while  the  appearance 
of  lactic  acid  may  be  long  delayed  or  never  present.  In  such  cases 
it  is  extremely  difficult  and  often  impossible  to  make  a  diagnosis 
with  certainty.     Exploratory  laparotomy  is  often  justifiable. 

Carcinoma  of  the  cardia,  as  a  rule,  offers  resistance  more  or  less 
marked  to  the  passage  of  a  sound;  especially  is  this  the  case  when 
the  lower  portion  of  the  esophagus  is  involved.  This  condition 
can  be  definitely  diagnosticated  by  means  of  the  Roentgen  ray  (see 
Plate  XI,  Fig.  2).  Roentgenology  is  frequently  of  great  assistance 
in  the  diagnosis  of  gastric  carcinoma  (see  Chapter  V — Plate  XIV, 
Fig.  1;  Plate  XV,  Figs.  3  and  4;  Plate  XVI,  Fig.  1). 

An  examination  of  the  stomach  contents  in  typical  cases  of 
gastric  carcinoma  reveals  the  presence  of  lactic  acid  (see  page  97) 
and  the  bacilli  of  Boas-Oppler  (Fig.  10,  B) ;  such  cases  are  marked 
by  the  absence  of  free  hydrochloric  acid.  The  color  of  the  gastric 
contents  is  frequently  brown  or  of  a  coffee-ground  appearance, 
owing  to  hemorrhages  from  the  carcinomatous  growth.  Micro- 
scopically, blood  and  pus  are  both  seen  in  the  gastric  contents  in 
cases  of  ulcerated  carcinoma.  The  test-diet  stool  is  characteristic 
(see  page  123).  Occult  hemorrhages  are  demonstrable  in  over  90 
per  cent,  of  the  cases  by  examination  of  the  feces.  In  cases  of 
achylia,  pepsin  is  often  found  in  the  urine  (see  page  97). 

For  the  glycyltryptophan,  Salomon,  Wolff-Junghans  and  Glu- 
zinski  tests,  see  pages  87  and  88. 

Serologic  Reactions. — While  serologic  reactions  are  inconclusive, 
and  even  the  most  suggestive  are  still  in  a  definitely  experimental 
stage,  much  progress  has  been  made  that  renders  it  necessary  to 
review  the  most  important  of  these  reactions. 

Hemolytic  Reactions. — In  the  growth  and  breaking  down  of  malig- 
nant tumors,  as  has  been  found  by  clinical  investigation,  substances 
are  formed  and  set  free  that  dissolve  the  red  blood-cells.  To  these 
substances,  or  lysins,  the  anemia  and  cachexia  of  malignant  disease 
have  been  ascribed.  Elsberg,  Xeuhof,  and  Geist,  reasoning  on  the 
assumption  that  the  blood  serum  of  patients  suffering  from  malig- 
nant disease  contains  hemolysins,  while  that  of  normal  individuals 
or  those  suffering  from  other  diseases  does  not,  maintain  that  in  this 
blood  phenomena  we  have  possibly  a  valuable  agency  for  the  diag- 
nosis of  malignant  disease.  They  have  accordingly  made  use  of  the 
hemolytic  property  of  the  blood  serum  of  carcinomatous  patients. 
They  inject  subcutaneously  into  the  forearm  of  the  suspected  car- 
cinomatous subject  5  minims  of  a  suspension  of  washed  human 
blood  corpuscles  (1 : 5)  in  salt  solution.  The  hemolysins  in  the  blood 
serum  of  a  carcinomatous  subject  attack  the  corpuscles  so  that  a 
reaction  shows  in  two  to  eight  hours.    The  skin  at  the  site  of  injec- 


544  TUMORS  OF  THE  STOMACH 

tion  exhibits  the  effect  in  a  color  varying  from  brownish-red  to 
bluish.  The  reaction  has  been  found  to  be  positive  in  89.9  per  cent, 
of  the  carcinomatous  cases  in  which  the  test  has  been  made. 

Kelling  has  shown  that  normal  blood  serum  will  hemolyze  the 
red  corpuscles  of  hen's  blood,  while  the  blood  serum  of  carcinoma- 
tous patients  will  not.  The  test  is  made  by  adding  1  Cc.  of  a 
5-per-cent.  saline  suspension  of  the  hen's  corpuscles  to  0.1  Cc. 
of  the  patient's  serum. 

Antitryptic  Reaction.- — When  the  blood  serum  of  a  carcinomatous 
patient  is  allowed  to  remain  on  a  Loeffler  serum  plate,  it  digests 
itself.  On  adding  normal  serum,  digestion  is  instantly  retarded, 
proving  the  existence  of  an  antiferment  in  normal  blood  serum. 

The  Miostagmin  Reaction.- — This  reaction  depends  upon  the 
fact  that  the  serum  of  a  carcinomatous  person,  if  treated  with  a 
standardized  reagent  containing  an  antigen  extracted  from  car- 
cinomatous tissue,  will  undergo  decreased  surface  tension  and 
the  drops  will  become  smaller.  They  must  be  measured  accurately 
with  an  instrument  of  precision  known  as  the  stalagmometer  of 
Traube.  The  serum  of  a  healthy  person  will  not  undergo  such 
change. 

The  reagent  is  obtained  by  cutting  up  the  carcinomatous  tissue 
and  drying  in  vacuo;  0.5  Gm.  of  this  powder  is  then  extracted  with 
25  Cc.  of  methyl  alcohol  at  50°  C.  in  a  closed  vessel  for  twenty- 
four  hours,  with  occasional  agitation.  This  alcoholic  solution 
is  then  diluted  with  distilled  water  to  such  a  point  that  when 
titrated  with  known  carcinomatous  serum  it  will  produce  an 
increase  in  the  number  of  drops  in  a  given  volume  to  the  extent 
of  50  per  cent,  as  compared  with  normal  serum.  To  9  Cc.  of 
the  serum  to  be  tested,  diluted  to  180  Cc.  with  saline  solution 
(0.85-per-cent.  sodium  chlorid),  1  Cc.  of  the  antigen  emulsion, 
standardized  as  above,  is  added.  After  incubation  for  one  hour 
at  50°  C.  the  number  of  drops  in  a  given  quantity  are  counted. 
The  control  consists  in  adding  distilled  water  instead  of  antigen 
emulsion  to  the  diluted  serum  and  incubating  under  the  same 
conditions — the  number  of  drops  in  a  given  quantity  being  counted 
both  before  and  after. 

Abderhalden  Reaction. — The  Abderhalden  serum  reaction  depends 
upon  the  fact  that  there  is  present  in  the  blood  of  patients  suffer- 
ing from  carcinoma  a  peculiar  digestive  ferment  not  found  in  the 
blood  of  healthy  persons.  This  ferment  is  produced  by  the  organ- 
ism in  an  effort  to  protect  itself  against  the  growth  of  the  carcinoma, 
hence  it  is  called  "protective."  It  is  capable  at  times  of  com- 
pletely digesting  the  carcinomatous  cell  invasion,  thus  curing  the 
patient.  When  the  invasion,  however,  has  advanced  as  far  as 
tumor  formation,  the  body  is  unable  to  combat  it. 

The  technic  of  the  serum  reaction  is  as  follows: 

The  blood  is  obtained  as  for  the  Wassermann  test,  about  10  Cc. 


CARCINOMA '  545 

being  required.  It  must  be  chemically  as  well  as  bacteriological! v 
clean.  Care  should  be  taken  not  to  shake  the  tube  containing  the 
blood,  as  shaking  is  apt  to  dissolve  some  of  the  hemoglobin,  and 
the  presence  of  hemoglobin  in  the  serum  invalidates  the  test. 

Carcinomatous  tissue,  to  be  used  in  the  test,  is  obtained  by 
cutting  up  pieces  of  carcinoma  of  the  breast,  thoroughly  washing 
in  distilled  water  until  the  biuret  test  applied  is  negative,  then 
boiling  for  thirty  minutes,  after  which  the  material  is  put  into 
chloroform-water  and  kept  on  ice.  A  small  portion  of  this  car- 
cinomatous tissue  is  placed  in  a  dialyzing  thimble,  and  2  Cc.  of 
the  blood  serum  to  be  tested  is  added.  The  thimble  containing 
the  mixture  is  placed  in  a  proper  container  filled  with  distilled 
water.  Toluol  is  added  to  the  dialyzer  and  the  container  to  pre- 
vent putrefaction.  The  whole  apparatus  is  placed  in  a  thermostat 
and  incubated  for  sixteen  hours.  At  the  end  of  this  time  the  dis- 
tilled water  surrounding  the  thimble  containing  the  serum  and 
carcinomatous  tissue  is  tested  for  the  presence  of  peptone  by  the 
ninhy drin  test.  A  positive  reaction  for  peptone  shows  that  the 
blood  serum  in  the  thimble  contains  a  proteolytic  ferment  capable 
of  disintegrating  carcinoma.  Xinhydrin  reacts  to  aminoacid  as 
well  as  to  peptone  and  is  preferable  to  biuret,  which  reacts  only 
to  peptone.  Controls  are  run  to  show  that  the  serum  alone  and 
carcinomatous  tissue  alone  do  not  give  positive  reactions. 

The  test  has  been  found  correct  in  a  number  of  cases  and  con- 
firmed by  operation  or  autopsy. 

Blood-sugar  Tolerance  Test. — Friedenwald  and  Grove1  believe 
this  test  to  be  of  distinctive  value  in  distinguishing  between  car- 
cinoma and  other  diseases  of  the  digestive  tract.  The  test  is  not 
specific  of  carcinoma,  but  it  has  an  important  bearing  if  diabetes, 
nephritis,  tuberculosis  and  thyroid  disturbances  can  be  excluded. 
It  has  been  known  for  some  time  that  hyperglycemia  is  present  in 
many  carcinomatous  cases,  especially  of  the  gastro-intestinal  tract. 
In  carcinoma  of  the  stomach  or  intestine  the  blood-sugar  tolerance 
test  shows  a  characteristic  curve  which  differs  from  that  observed 
in  carcinoma  of  other  regions  of  the  body.  This  curve  presents  a 
high  sugar  content,  even  in  the  fasting  state,  followed  by  an  initial 
rise  up  to  0.24  per  cent,  or  even  higher  within  forty-five  minutes 
after  the  ingestion  of  the  dextrose,  remaining  at  this  level  for  at 
least  two  hours  and  at  no  time  falling  below  0.20  per  cent. 

The  test  is  carried  out  in  the  following  manner:  After  a  night's 
fast,  100  grams  of  dextrose  is  dissolved  in  300  Cc.  of  black  coffee 
and  given  to  the  patient  before  breakfast.  Just  before  this  is  given, 
blood  is  taken  for  a  sugar  test,  and  this  procedure  is  repeated  forty- 
five  minutes  and  one  hundred  and  twenty  minutes  after  the  ingestion 
of  the  sugar.    In  an  individual  in  good  health  there  is  an  increase 

1  Friedenwald  and  Grove:     The  Blood-sugar  Tolerance  Test  as  an  Aid  in  the 
Diagnosis  of  Gastro-intestinal  Cancer,  American  Journal  of  the  Medical  Sciences, 
September,  1920. 
35 


546  TUMORS  OF  THE  STOMACH 

in  the  blood-sugar,  reaching  its  maximum  in  forty-five  minutes, 
and  then  gradually  falling  to  normal,  which  is  0.08  to  0. 12  per  cent. 
In  patients  with  carcinoma  of  the  stomach  or  intestine  the  blood- 
sugar  shows  a  rise  in  forty-five  minutes,  after  which  time  it  may 
continue  to  rise  or  remain  stationarily  high  for  two  hours  after  the 
glucose  meal.  Subsequently  the  blood-sugar  gradually  recedes, 
becoming  normal  in  three  to  four  hours  after  the  feeding. 

Linitis  plastica  hypertrophica  (leather-bottle  stomach)  is  a 
sclerosing  pyloric  and  diffuse  fibrocarcinoma.  It  is  a  condition 
in  which  there  is  a  great  thickening  of  the  walls  of  the  stomach, 
due  to  fibrosis  involving  mainly  the  submucous  and  to  some  extent 
the  other  coats.  The  mucous  membrane  itself  does  not  seem  to 
be  involved.  The  hypertrophy  is  so  great  that  the  lumen  of  the 
stomach  is  very  much  reduced.  The  fibrosis  may  be  limited  in 
extent,  though  usually  the  entire  stomach  is  involved.  The  thick- 
ened wall  is  very  rigid  and  may  be  six  to  ten  times  the  normal 
size.  The  duodenum  is  rarely  implicated.  The  connective-tissue 
proliferation  is  the  most  striking  feature  of  this  disease.  The 
disease  is  one  of  adult  life,  and  the  patients  are  usually  between 
the  ages  of  forty  and  sixty,  and  about  twice  as  often  men  as  women. 
Roentgen-ray  examination  offers  the  best  means  of  recognizing  the 
lesion.  The  Roentgen  fluoroscope  shows  the  rapid  emptying  of 
the  stomach  as  the  bismuth  flows  without  hindrance  through  the 
rigid  gastric  lumen  into  the  duodenum.  Serial  roentgenograms 
indicate  the  degree  of  stenosis  (see  page  142). 

Treatment. — The  treatment  of  carcinoma  of  the  stomach  is 
essentially  surgical.  The  physician  should  therefore  endeavor  to 
ascertain  precisely  the  chances  offered  by  operation  in  each  indi- 
vidual case  before  employing  internal  medication,  which  is  at 
best  palliative  and  in  no  sense  curative.  As  soon  as  the  diag- 
nosis of  carcinoma  of  the  stomach  is  confirmed,  the  case  should 
be  referred  to  the  surgeon  without  delay.  The  value  of  surgery  in 
early  diagnosis  is  shown  by  my  longest  living  case.  She  had  one 
half  of  the  stomach  resected  for  pyloric  carcinoma  five  years  and 
eight  months  ago,  and  at  this  writing  she  seems  perfectly  well. 

Internal  Treatment. — Internal  or  palliative  treatment  is 
indicated  in  those  cases  which,  after  careful  study  and  examina- 
tion, are  found  to  be  unsuitable  for  surgical  treatment.  Medica- 
tion must  proceed  along  symptomatic  lines.  An  endeavor  should 
be  made,  on  the  one  hand,  to  retard  or  inhibit  the  growth  of  the 
neoplasm,  while  on  the  other  the  subjective  symptoms  of  the  patient 
should  be  relieved  to  the  greatest  possible  extent.  Complete 
rest,  both  physical  and  mental,  should  be  procured  for  the  patient; 
he  should  occupy  the  recumbent  position  as  much  as  possible,  and 
retire  early  at  night,  since  physical  rest  conserves  the  heat  of  the 
body;  in  this  way  the  nutrition  may  be  most  advantageously 
maintained. 


CARCINOMA  .".17 

Diet. — Diet  is  of  first  importance  in  the  internal  treatment  of 

carcinoma  of  the  stomach.  Of  necessity  small  in  quantity,  it 
should  be  limited  to  articles  of  food  with  a  high  nutritive  value;  food 
containing  the  greatest  number  of  calories,  and  which  is  at  the  same 
time  non-irritating  in  its  nature,  should  be  prescribed. 

The  regimen  for  a  carcinomatous  patient  should  be  of  such 
variety  as  to  keep  the  appetite  stimulated  as  long  as  possible. 
Anorexia  is  found  to  be  the  greatest  impediment  to  the  nutrition  of 
these  patients.  Owing  to  the  tendency  to  stagnation  of  the  food 
mass  in  the  stomach,  and  consequent  fermentation,  the  meals 
should  be  small  and  frequent.  The  character  of  the  diet  should 
be  adapted  as  largely  as  possible  to  the  condition  of  the  gastric 
secretion — free  hydrochloric  acid  being  regarded  as,  to  a  certain 
extent,  an  indicator  for  the  prescription  of  proteins.  The  reader 
is  referred  to  Chapter  XXIII  on  Subacidity  and  Anacidity  for 
dietary  measures  covering  those  conditions  of  secretion.  The  ques- 
tion of  motor  disturbance  should  be  kept  in  mind,  and  in  the 
presence  of  marked  stenosis  the  diet  should  be  that  laid  down  for 
the  treatment  of  motor  insufficiency  of  the  second  degree  (see 
Chapter  XXIV).  In  all  cases  of  carcinoma  of  the  stomach  the 
diet  should  be  of  liquid  or  semiliquid  consistency;  the  necessity 
for  this  is  greater  in  the  more  marked  stenoses  of  the  pylorus  and 
in  cases  with  a  tendency  to  hemorrhage.  Of  the  liquid  nutrients, 
milk  occupies  the  first  place;  it  may  be  prescribed  very  much 
according  to  the  desires  of  the  patient — alone  or  with  tea,  coffee, 
cocoa,  or  leguminous  flours.  Should  milk  become  distasteful, 
buttermilk,  sour  milk,  kefir,  milk  of  almonds,  milk  soups,  all  form 
agreeable  substitutes.  Tastily  prepared  soups  made  from  legumi- 
nous flours  with  eggs  and  butter,  vegetable  purees,  flour  puddings 
with  fruit  sauces,  and  malt  extract  free  from  fermentative  pro- 
cesses, constitute  valuable  dietetic  agents  in  this  condition.  Next 
to  milk,  eggs  are  most  suitable  for  these  patients;  they  may  be 
prescribed  soft-boiled,  scrambled,  as  omelets,  or  raw  beaten  up 
with  sugar  and  wine. 

Fat  may  be  prescribed  in  large  quantities  so  long  as  the  fer- 
mentative process  in  the  stomach  is  not  too  pronounced;  it  should 
be  in  the  form  of  butter,  olive  oil,  or  chocolates  rich  in  fat.  Meat 
should  be  given  thoroughly  boiled  or  roasted,  and  finely  divided, 
preferably  in  the  form  of  chopped  meat.  Should  meat  become 
distasteful,  meat  jellies  may  be  tried;  or,  if  the  patient's  repug- 
nance to  meat  in  any  form  is  marked,  it  would  be  well  to  omit  it 
altogether  from  the  dietary  for  a  few  days.  Light  cheese  may 
be  prescribed.  Zwieback,  biscuits  and  toast  must  be  softened 
before  being  eaten.  All  vegetables  should  be  served  in  the  form 
of  puree. 

The  habits  of  life  and  the  desires  and  tastes  of  the  patient 
should  not  be  disregarded  entirely  in  prescribing  diet.     Various 


548  TUMORS  OF  THE  STOMACH 

kinds  of  delicacies  may  be  incorporated  in  the  menu.  The  mental 
impression  produced  by  the  addition  of  a  few  luxuries,  as  well  as 
the  preparation  and  serving  of  food  in  an  attractive  manner,  is 
sure  to  have  a  favorable  effect  upon  the  patient.  Monotony  in 
diet  should  be  carefully  avoided,  to  keep  up  a  fair  appetite  and 
counteract  as  far  as  possible  the  distaste  for  food  which  is  too 
often  a  characteristic  symptom  of  the  disease.  I  would  say,  then, 
that  a  patient  without  marked  stenosis  of  the  pylorus  may  partake 
of  a  wide  range  of  food  so  long  as  the  various  dietetic  articles  agree 
with  him.  It  is  often  possible  to  keep  the  patient  fairly  well 
nourished  for  a  considerable  length  of  time.  The  greatest  obstacle 
is  encountered  with  that  class  of  patients  whose  financial  circum- 
stances will  not  permit  of  such  a  varied  diet  as  outlined. 

In  case  of  gastric  hemorrhage  resulting  from  carcinoma  of  the 
stomach,  the  patient  should  assume  the  recumbent  position.  The 
diet  in  this  condition  should  be  as  prescribed  in  Chapter  XXVI 
on  Hemorrhage. 

In  cases  in  which  it  is  extremely  difficult  to  maintain  nutrition 
by  oral  feeding,  as  in  severe  pyloric  stenosis  with  troublesome 
vomiting,  nutrient  enemata  should  be  employed,  but  only  as  an 
adjunct  to  oral  feeding.  Exclusive  rectal  alimentation  should  not 
be  attempted,  even  for  a  few  days,  since  it  has  been  found  that 
in  carcinoma  inanition  results  more  rapidly  under  this  regimen 
than  with  even  a  minor  degree  of  oral  alimentation  alone  (see 
page  243). 

Treatment  by  Lavage. — Washing  out  the  stomach  in  gastric 
carcinoma  is  an  important  auxiliary  to  the  dietetic  treatment. 
Lavage  is  indicated  when  the  motor  function  of  the  stomach  is 
disturbed.  It  is  especially  indicated  in  pyloric  stenosis  with  motor 
insufficiency  of  the  second  degree,  as  well  as  in  motor  insufficiency 
of  the  first  degree.  In  the  latter  condition  it  is  not  necessary  to 
wash  the  stomach  every  day.  In  motor  insufficiency  of  the  second 
degree,  however,  daily  lavage  should  be  performed,  preferably  at 
night  before  dinner.  This  daily  lavage  has  the  happy  effect  of 
relieving  patients  of  many  of  their  distressing  symptoms;  vomit- 
ing ceases,  the  pains  decrease  in  severity,  the  appetite  improves, 
and  there  is  a  marked  improvement  in  the  nutrition.  Patients 
take  on  new  hope,  which  is  an  important  matter  in  the  treatment 
of  gastric  carcinoma.  Lavage,  however,  will  not  arrest  the  cachexia 
resulting  from  carcinoma;  yet,  in  spite  of  the  gradually  progressive 
weakness,  patients  remain  free  from  many  subjective  symptoms 
which  would  otherwise  render  their  existence  a  greater  burden. 
Lavage  should  be  followed  up  by  irrigation  with  antifermentative 
solutions,  especially  when  there  is  marked  formation  of  gas  as 
shown  by  eructations.  The  lavage  process  should  not  be  pro- 
longed, since  it  requires  more  or  less  effort  on  the  part  of  the  patient 
(see  page  197). 


CARCINOMA  549 

M im-nil-initrr  Cures.  Mineral  waters  have  not  been  found 
satisfactory  in  the  treatment  of  gastric  carcinoma.  Sojourn  at 
the  so-called  health  resorts  has  not  been  attended  by  any  marked 
improvement  in  the  condition  of  the  patient. 

Physical  Treatment. — This  consists  of  local  applications  in 
the  form  of  moist  trunk  packings,  or  hot  moist  or  dry  stupes  applied 
in  the  gastric  region  to  counteract  the  feeling  of  gastric  pressure, 
pains,  and  nausea  (see  Chapter  XII).  Massage  and  electricity  are 
not  indicated  in  gastric  carcinoma. 

Medicinal  Treatment. — The  use  of  drugs  in  the  treatment  of 
carcinoma  of  the  stomach  is  confined  almost  entirely  to  the  relief 
of  distressing  symptoms.  Condurango  bark  has  been  employed 
most  frequently  as  a  medicinal  agent  for  the  stimulation  of  the 
appetite  (see  page  267),  and  was  believed  at  one  time  to  possess 
remedial  virtues.  But  while  no  drug  has  been  found  to  exert  any 
influence  upon  the  course  of  the  disease,  condurango  is  still  worthy 
of  trial  as  a  stomachic.  It  ameliorates  nausea,  vomiting,  and  pain, 
and  on  this  account  is  to  be  preferred  to  the  other  bitter  tonics. 
It  is  administered  in  the  form  of  a  decoction: 

Gm.  or  Cc. 

1$ — Corticis  condurango 15 1 0  5ss 

Macerate  for  twelve  hours  with  dis- 
tilled water    .      .      .  _    .      .      .      .     360(0  gxij 
Sig. — Tablespoonful  three  times  a  day,  before  meals. 

In  addition  to  condurango  bark,  the  cinchona  preparations, 
tincture  of  gentian,  and  orexin  may  be  prescribed  (see  page  267). 

In  subacidity  and  anacidity,  pepsin  and  hydrochloric  acid  may 
be  employed  for  the  purpose  of  increasing  proteolysis  (see  page 
258). 

As  an  anodyne,  tincture  of  valerian  or  compound  spirit  of  ether 
is  indicated.  ^Yhen,  however,  the  pains  are  severe,  orthoform  or 
anesthesin  may  be  employed;  or  if  so  severe  as  to  require  the 
administration  of  some  narcotic,  codein  or  extract  of  belladonna 
may  be  administered  in  the  form  of  rectal  suppositories  as  well  as 
by  mouth.  Morphin  should  be  reserved  until  the  final  stages  of 
the  disease. 

Cocain  or  3  to  5  minims  of  chloroform  on  small  pieces  of  ice 
may  be  given  for  the  vomiting. 

For  distress  caused  by  excessive  gaseous  fermentation,  antiseptic 
drugs  (see  page  272)  occasionally  give  good  results: 

Gm.  or  Cc. 


1^ — Resorcinolis, 

Tincturse  opii aa        2 

Aquse 180 

Syrupi q.  s.  ad     200 

Misce. 

Sig. — One  tablespoonful  every  two  hours. 


0  3ss 

0  5vj 

0  5vij 


550  TUMORS  OF  THE  STOMACH 

Autolysin  or  protect!  is  the  name  of  a  new  remedy  for  carcinoma. 
Consisting  at  first  of  a  variety  of  vegetable  proteins,  organic  salts, 
extractive  materials,  chlorophyl,  chromophyl,  and  lipoids,  from 
plant  substances  little  used  in  medicine,  it  is  now  prepared  from 
alfalfa  meal,  alfalfa  seed,  and  millet  seed.  The  solution  contains 
proteins,  proteoses,  and  peptone,  neutralized  with  sodium  hydroxid. 
The  dose  is  0.3  to  1.5  Cc.  (5  to  25  minims)  injected  hypodermically 
into  the  forearm.    The  value  of  the  treatment  is  doubtful. 

The  medicinal  treatment  of  gastric  hemorrhage  resulting  from 
carcinoma  is  the  same  as  that  of  gastric  hemorrhage  from  other 
causes   (see  Chapter  XXVI). 

Attempts  have  been  made  to  directly  influence  the  growth  of 
carcinoma  of  the  stomach  by  means  of  drugs.  Temporary  relief 
has  been  reported  from  the  use  of  arsenic  in  the  form  of  Fowler's 
solution,  administered  over  a  long  space  of  time  in  gradually 
increasing  doses.  Sodium  cacodylate  may  be  given  in  larger  doses, 
0.1  to  0.5  Gm.  (1|  to  1\  grains)  in  sterile  solution  hypodermically. 
A  few  clinicians  have  reported  a  temporary  diminution  in  the 
size  of  the  tumors,  as  well  as  improvement  in  the  general  con- 
dition, from  the  protracted  administration  of  methylene  blue. 
This  drug  may  be  given  in  pill  form,  0.06  Gm.  (1  grain)  three  times 
a  day,  or  in  suppositories,  0.06  Gm.  with  0.02  Gm  (f  grain)  of 
extract  of  belladonna  to  each  suppository.  Of  other  drugs  which 
have  been  used  to  inhibit  the  growth  of  the  neoplasm,  or  if  possible 
diminish  its  size,  chlorinated  soda  and  chelidonium  might  be 
mentioned. 

Adamkiewicz  has  employed  a  serum  called  cancorin,  which  is 
of  doubtful  value.  The  carcinoma-cure  serum  of  Doyen  is  prob- 
ably also  without  much  merit.  Good  results  in  the  way  of  pro- 
ducing a  shrinking  and  softening  of  the  carcinomatous  masses 
have  been  reported  from  the  use  of  cancrodin  (antimeristem),  pre- 
pared by  Schmidt,  of  Cologne,  from  killed  cultures  of  Mucor 
racemosus;  it  causes  a  febrile  reaction  and  inflammatory  manifes- 
tations. 

Radiation  Treatment. — Success  in  the  treatment  of  carcinoma 
has  been  reported  from  the  use  of  the  Roentgen  ray;  under  its 
influence  gastric  tumors  have  wholly  disappeared.  Einhorn  has 
used  radium  in  the  treatment  of  gastric  as  well  as  esophageal  car- 
cinomata.  The  radium  is  deposited  in  a  hard-rubber  capsule,  the 
parts  of  which  are  connected  by  screw  threads;  the  capsule  is 
attached  to  a  silk  cord  about  75  centimeters  in  length  and  intro- 
duced into  the  stomach  in  the  same  manner  as  the  stomach  bucket 
(see  page  70) .  There  it  is  retained  for  an  hour  at  a  time.  Accord- 
ing to  Einhorn  the  results  of  the  radium  treatment  have  been 
satisfactory,  especially  in  esophageal  carcinoma.  Radio-active 
treatment  is  therefore  destined  to  play  an  important  role  in  the 
therapeutics  of  carcinoma  of  the  esophagus,  and  deserves,  to  be 
tried  on  a  large  scale  and  in  a  thorough  manner. 


CARCINOMA  551 

In  the  radium  treatment  of  gastric  carcinoma,  one  great  diffi- 
culty is  to  locate  the  process  and  place  the  radium  near  enough  to 
produce  any  effect.  Powerful  as  it  is,  radium  cannot  destroy  the 
cancer  cell  at  a  greater  distance  than  four  centimeters  (1£  to  1| 
inches).  Another  difficulty  has  been  lack  of  standardization  of 
radium  itself.  Neither  of  these  difficulties  is  essentially  insur- 
mountable. 

Treatment  of  Carcinoma  of  the  Cardia. — The  diet  should  be  care- 
fully regulated,  to  minimize  the  difficulties  of  deglutition  which 
accompany  stenosis  of  the  cardia,  when  the  seat  of  the  carcinoma 
is  the  cardiac  entrance  to  the  stomach.  It  should  be  such  as  to 
produce  as  little  irritation  as  possible  at  the  cardiac  orifice.  The 
use  of  bland  food,  soft  in  consistency,  will,  to  a  large  extent,  ward 
off  the  tendency  to  disintegration  of  the  tumor-like  mass,  and 
prevent  hemorrhages  and  rapidity  of  growth.  Meats  should  be 
given  in  finely  divided  form,  and  potatoes,  vegetables  and  pre- 
served fruit  as  puree  only.  Flour-and-milk  soups,  eggs,  milk, 
cream  and  artificially  prepared  foods  may  be  prescribed  so  long  as 
they  can  be  swallowed  with  ease.  The  maintenance  of  the  general 
nutrition  will  not  be  a  difficult  matter,  since  the  articles  mentioned 
may  be  taken  in  large  quantities.  As  the  cardiac  stenosis  becomes 
more  marked,  the  question  of  adequately  nourishing  the  patient 
assumes  a  graver  aspect.  The  diet  must  eventually  be  entirely 
liquid. 

Patients  may  partake  of  the  following  ad  libitum:  Wine,  beer, 
milk,  buttermilk,  kefir,  fruit  juices,  mineral  waters,  vanilla  ice- 
cream, and  artificial  food  preparations.  They  can  be  sustained  for 
a  long  time  with  the  above  regimen,  providing  the  painful  symptoms 
are  not  such  as  to  prevent  them  from  swallowing  the  liquid  nour- 
ishment. When  patients  are  unable  to  consume  even  liquid  diet, 
owing  to  difficulties  in  deglutition,  a  good  quality  of  olive  oil  should 
be  administered  in  generous  amount.  The  oil  has  the  effect  of 
lubricating  the  stenosed  cardia  so  that  food  will  pass  into  the 
stomach  more  easily.  Sometimes  the  inability  to  swallow  arises 
more  from  the  inflamed  condition  of  the  cardia  than  from  the 
degree  of  stenosis;  the  oil  in  such  cases  serves  the  purpose  of  a 
protective  layer  upon  the  neoplasm,  rendering  it  less  sensitive  and 
thereby  preventing  spastic  contraction  of  the  cardiac  orifice.  Olive 
oil,  moreover,  has  a  high  nutritive  value.  At  least  half  a  wineglass 
of  the  oil  should  be  taken  morning,  noon  and  night,  half  an  hour 
before  ingestion  of  other  food.  Almond  milk  is  the  most  efficient 
substitute  for  olive  oil,  should  the  latter  become  distasteful  to  the 
patient.  When  the  stricture  becomes  so  marked  as  to  preclude 
the  passage  of  even  liquids,  aided  in  their  passage  by  the  oil,  then 
whatever  is  partaken  of  by  mouth  lodges  in  the  lower  portion  of 
the  esophagus,  above  the  constriction,  only  to  be  expelled  by 
vomiting.    Systematic  lavage  of  the  esophagus  may  be  performed, 


552  TUMORS  OF  THE  STOMACH 

by  means  of  the  ordinary  soft  stomach  tube  introduced  as  far  as 
the  stricture.  When  the  food  remnants  are  removed  the  lavage 
process  should  be  continued  with  small  quantities  of  warm  water 
until  all  mucus,  pus  and  blood  is  washed  away.  The  esophagus 
may  be  rinsed  with  mild  antiseptic  solutions.  After  the  rinsing 
process,  30  to  60  Cc.  (Sj-ij)  of  olive  oil  should  be  injected  into 
the  esophagus  with  the  esophageal  syringe  (Fig.  68).  Esophageal 
lavage  should  be  performed  at  first  once  a  day,  and  later  on  every 
second  day.  Food  may  be  taken  one  hour  after  the  lavage. 
Patients,  as  a  rule,  are  very  much  relieved  by  the  systematic  wash- 
ing and  lubrication;  the  irritability  of  the  diseased  area  is  allayed, 
and  frequently  deglutition  is  facilitated.  It  is  possible  to  improve 
conditions  for  a  time  by  having  the  patients  sip  every  hour  a  1-  or 
2-per-cent.  solution  of  hydrogen  dioxid.  Some  patients  are  thus 
restored  to  comparative  comfort  and  enabled  to  resume  taking 
nourishment  by  mouth  (see  page  272). 

By  regularly  sounding  and  dilating  the  cardiac  stricture  the 
progress  of  the  stenosis  may  be  inhibited  for  a  considerable  length 
of  time  (see  page  368).  Some  clinicians,  however,  are  opposed  to 
the  use  of  the  sound,  fearing  mechanical  irritation  that  may  stimu- 
late the  carcinoma  to  further  growth.  It  is  true  that  damage 
may  result  from  the  injudicious  use  of  the  sound.  Mechanical 
dilatation  of  the  carcinomatous  stricture  should  not  be  considered 
so  long  as  the  patient  is  able  to  swallow  a  sufficient  quantity  of 
liquid  and  semisolid  nourishment  to  maintain  nutrition.  When, 
however,  this  cannot  be  done,  the  physician  may  succeed  in  so 
far  dilating  the  stricture  as  to  enable  the  patient  to  swallow  with 
comparative  ease.  The  stomach  tube  may  be  utilized  for  the  intro- 
duction of  nourishment  into  the  stomach.  Any  food  introduced 
through  the  tube  should  be  of  a  concentrated  nature,  representing 
the  highest  percentage  of  calories  per  unit  of  volume.  The  food 
may  consist  of  a  pint  of  milk,  with  somatose  or  other  protein 
preparation,  two  or  three  eggs,  three  ounces  of  sugar,  malt  extract 
or  dextrinized  milk,  wine  and  salt.  When  the  feeding  by  mouth 
(or  tube)  is  not  sufficient,  rectal  alimentation  may  be  employed 
for  a  few  days.  Analgesic  and  antispasmodic  drugs  are  sometimes 
prescribed,  to  diminish  the  difficulties  of  swallowing.  Morphin  or 
cocain  may  be  swallowed  as  drops  or  tablets;  the  following  is  very 
useful : 

Gm.  or  Cc. 
fy — Morphinse  hydrochloride 


Cocainse  hydrochloridi       .      .      .   aa    0 

Antipyrinae 0 

Sacchari .      .     0 

Misce  et  ft.  tab.  no.  i. 

Sig. — One  tablet  before  partaking  of  food. 


0025  gr.  jfc 

1  gr.  iss 

3  gr.  v 


Solutions  of  5-per-cent.  cocain  or  3-per-cent.  eucain  may  be 
injected  directly  as  far  as  the  cardiac  orifice  by  means  of  a  small 
stomach  tube  or  a  long  soft-rubber  catheter  attached  to  an  ordinary 
piston  syringe  (Fig.  68,  page  354). 


SARCOMA  553 


SARCOMA. 


While  carcinoma  is  a  comparatively  frequent  affection  of  the 
stomach,  primary  gastric  sarcoma  is  rare.  Hosch,  in  13,387 
autopsies,  found  but  six  primary  gastric  sarcomata,  and  Tilger, 
in  3500  autopsies,  found  only  one.  Although  an  admittedly  rare 
condition,  recent  research  has  shown  that  many  cases  diagnosti- 
cated as  carcinoma  have  upon  reinvestigation  proved  to  be  of 
the  sarcomatous  type.  Perry  and  Shaw,  on  examining  50  cases 
of  so-called  carcinoma  ventriculi  obtained  from  Guy's  Hospital 
Museum,  London,  discovered  that  four  of  the  specimens  were 
round-celled  sarcoma.  According  to  Fenwick,  5  to  8  per  cent,  of 
all  primary  neoplasms  of  the  stomach  are  to  be  classed  as  sarcomata. 

Etiology. — Of  the  etiology  of  gastric  sarcoma  very  little  is  known. 
Heredity  and  trauma  have  been  considered  as  positive  predisposing 
influences.  Ulcer  of  the  stomach  is  but  rarely  the  starting-point  of 
sarcoma.  Sex  seems  to  have  little  or  no  influence  as  a  determining 
factor.  The  majority  of  cases  are  noted  between  the  ages  of  forty 
and  fifty  years. 

Pathology. — Sarcoma  is  a  neoplasm  consisting  of  small  cells  of 
an  adenoid  or  embryonic  type,  without  epithelial  appearance  and 
in  many  cases  without  stroma.  We  speak  of  round-  or  spindle- 
celled  sarcoma,  according  to  the  character  of  the  cell.  Primary 
gastric  sarcoma  occurs  in  two  forms — infiltrated  and  circumscribed. 
Round-celled  sarcomata  develop  from  the  trabecular  tissue  of  the 
gastric  submucosa;  lymph osarcomata  from  the  lymphatic  nodules 
of  the  subserous  coat.  The  usual  location  or  starting  point  of 
lymphosarcomata  is  the  pylorus;  this  variety  of  neoplasm  often 
infiltrates  the  entire  wall  of  the  stomach,  but,  as  a  rule,  avoids 
the  gastric  orifices.  Next  in  frequency  is  the  myosarcoma,  having 
its  starting-point  in  the  muscular  coat.  Fibrosarcomata  and  myxo- 
sarcomata  are  very  rare.  Myo-  and  fibrosarcomata  represent  the 
circumscribed  form  of  sarcoma,  which  often  acquires  an  enormous 
size,  with  frequent  metastases;  especially  is  this  true  of  round- 
celled  sarcomata  and  lymphosarcomata,  which  invade  the  peri- 
toneal lymphatic  glands,  the  pleural  cavities,  the  kidneys,  ovaries, 
spleen,  liver,  and  lungs.     Metastases  in  the  skin  are  very  rare. 

Symptoms. — The  clinical  course  of  gastric  sarcoma  is  subject 
to  great  variation.  In  some  cases  symptoms  have  been  present 
for  years,  while  in  others  the  first  dyspeptic  symptoms  were  coin- 
cident with  a  discovery  of  the  tumor.  In  some  cases  where  the 
tumor  was  readily  palpable  the  subjective  symptoms  were  very 
slight.  Cachexia,  as  a  rule,  occurs  very  late  in  the  disease.  Owing 
to  the  fact  that  gastric  sarcoma  seldom  produces  stenosis,  emesis 
is  apt  to  be  absent  throughout  the  course  of  the  disease.  Pains 
in  the  region  of  the  stomach  appear  early  and  may  be  very  severe. 
Free  hydrochloric  acid  is  absent  in  the  majority  of  cases.    Lactic 


554  TUMORS  OF  THE  STOMACH 

acid  is  often  found  when  hydrochloric  acid  is  absent.  The  Boas- 
Oppler  bacilli  are  not  constantly  present  in  gastric  sarcoma.  Marked 
degrees  of  anemia  develop  during  the  progress  of  the  disease.  Hem- 
orrhages occasionally  take  place,  though  death  from  hemorrhage 
is  exceedingly  rare. 

Diagnosis.- — The  Roentgen  ray  is  of  great  assistance  in  the  diag- 
nosis. The  importance  of  an  early  differential  diagnosis  between 
carcinoma  and  sarcoma  of  the  stomach  cannot  be  overestimated, 
since  the  timely  surgical  treatment  of  sarcoma  is  frequently  followed 
by  gratifying  results.  Of  26  cases  of  sarcoma  in  which  resection 
was  done,  11  were  reported  successful.  Lymphosarcomata  appear 
to  be  especially  adapted  for  operative  intervention.  The  results 
depend,  of  course,  entirely  upon  the  time  of  operation. 

Many  cases  of  gastric  sarcoma  cannot  be  distinguished  clinically 
from  gastric  carcinoma;  especially  is  this  true  of  the  round-celled 
type.  Sarcoma  is  apt  to  occur  at  a  much  earlier  age  than  car- 
cinoma. Softening,  hemorrhage  and  perforation  occur  but  rarely 
in  gastric  sarcoma.  Owing  to  the  fact  that  sarcoma  is  an  infil- 
trating growth,  there  is  usually  no  contraction  and  no  obstruction. 
If  obstruction  does  occur,  it  is  mechanical  rather  than  due  to  a 
constriction  of  the  growth. 

As  an  aid  to  the  differential  diagnosis  the  reader  is  referred  to 
the  following: 

Differential  Diagnosis. 


Gastric  Carcinoma. 

Gastric  Sarcoma. 

1. 

Much  pain. 

Much  pain  early,  which  diminishes  as 
the  tumor  becomes  palpable.  Some- 
times no  pain  at  all. 

2. 

Involvement  of  the  orifices. 

Orifices  either  not  involved  or  rarely 
involved. 

3. 

Stenosis  marked. 

Stenosis  seldom. 

4. 

Hemorrhage  early. 

Hemorrhage  late  in  the  course  of  the 
disease. 

5. 

Markedly  malignant. 

Less  malignant. 

6. 

Growth  rapid. 

Growth  comparatively  slow. 

7. 

Metastases  early. 

Metastases  late. 

S. 

Cachexia  early. 

Cachexia  late. 

Treatment. — The  treatment  of  gastric  sarcoma  is  essentially 
surgical.  ^Vhen  for  any  reason  surgical  intervention  would  be 
injudicious  or  not  likely  to  be  followed  by  beneficial  results,  the 
palliative  treatment  is  that  already  described  for  gastric  carcinoma. 

Coley  reports  remarkably  good  results  from  the  hypodermic 
injection  of  mixed  toxins  (the  toxins  of  erysipelas  and  the  Bacillus 
prodigiosus)  in  the  treatment  of  inoperable  sarcoma.  The  doses 
are  small,  not  more  than  J  to  |  minim  to  begin  with,  increased  to 
the  point  of  marked  febrile  reaction.  He  states  that  if  benefit  is 
to  be  expected  it  will  be  manifest  within  three  weeks  after  the 
toxin  treatment  is  instituted. 


HERNIA  EPIGASTRICA  555 

BENIGN  TUMORS. 

Benign  tumors  of  the  stomach  are  of  exceedingly  rare  occur- 
rence. They  seldom  give  rise  to  any  symptoms  during  life,  though 
occasionally  ulceration  of  the  tumor,  hemorrhage,  or  even  obstruc- 
tion may  occur.  Such  growths  are,  as  a  rule,  discovered  at  autopsy. 
They  arc  simple  or  multiple,  sessile  or  pedunculated.  They  are 
classified  according  to  the  tissues  or  gastric  layers  from  which  they 
are  derived.  Among  tumors  derived  from  the  glandular  structure, 
or  gastric  mucosa,  are  mucous  polypi,  mucous  papilloma  and  ade- 
noma-— small,  multiple,  sessile  or  pedunculated  growths;  individ- 
ually they  are  seldom  larger  than  a  small  bean.  They  are  commonly 
found  near  the  cardia,  rarely  in  the  region  of  the  pylorus. 

Tumors  derived  from  connective  tissue  are:  (a)  Lipomata,  or 
fatty  tumors  arising  from  the  submucosa  in  any  part  of  the  gastric 
walls,  (b)  Fibromata.  Some  of  the  older  writers  described  these 
as  probably  slow-growing  carcinomata  with  much  fibroid  stroma. 
To  this  class  belong  the  fibrous  thickenings  of  the  pylorus  due  to 
spasm  or  chronic  inflammation  or  resulting  from  an  old  cicatrizing 
ulcer.  True  fibromata  are  villous  growths,  usually  covered  wTith 
a  single  layer  of  cylindric  cells;  they  are  often  polypoid  and  pedun- 
culated, (c)  Fibromyomata — benign  tumors  which  project  into 
the  stomach.  These  consist  of  unstriped  muscle  fibers  in  the 
fibrous  tissue,  with  the  mucous  membrane  covering  intact.  They 
develop  in  the  muscular  layer  of  the  stomach  wall,  are  rarely  larger 
than  a  pea,  and  produce  no  symptoms. 

Cysts  of  the  stomach  are  usually  formed  by  the  occlusion  of  a 
duct  of  a  gastric  gland ;  they  may  attain  the  size  of  a  small  walnut, 
but  are  usually  very  small  and  multiple,  having  the  appearance  of 
groups  of  minute  vesicles. 


HERNIA  EPIGASTRICA. 

Hernia  epigastrica  consists  of  a  rupture  occurring  at  some  part 
of  the  linea  alba  between  the  umbilicus  and  the  ensiform  cartilage. 
It  belongs  to  the  class  of  preperitoneal  lipomata,  is  made  up  of 
omentum  and  fat,  and  varies  in  si^e  from  a  bean  to  an  egg.  The 
regions  must  be  carefully  palpated  in  order  to  diagnosticate  epigas- 
tric hernia;  with  a  tumor  of  considerable  size,  there  may  be  felt 
at  the  tips  of  the  fingers  a  sensation  as  though  small  shot  were 
hitting  them  when  the  patient  coughs. 

Hernia  epigastrica  may  produce  symptoms  simulating  those  of 
almost  any  gastric  disease,  and  for  that  reason  it  is  of  the  greatest 
importance  that  an  accurate  diagnosis  be  made.  The  condition 
has  been  mistaken  for  gastric  ulcer,  gastritis,  gastralgia,  carcinoma, 
enteritis,  cholelithiasis,  and  nervous  dyspepsia  (see  page  419). 


556  TUMORS  OF  THE  STOMACH 

One  case  of  mine/  reported  in  1897,  had  been  previously  treated 
for  over  four  years  for  a  presumed  chronic  gastritis.  There  were, 
with  intervals  of  freedom  from  symptoms,  recurring  attacks  of 
nausea,  vomiting,  epigastric  pain,  and  anorexia.  The  patient  lost 
28  pounds  in  four  months  on  account  of  his  persistent  inability 
to  retain  food.  After  the  removal  of  the  tumor,  which  was  not 
known  to  the  patient  as  hernia,  a  speedy  recovery  took  place.  The 
patient  continued  well,  without  any  gastric  symptoms,  for  eighteen 
years. 

The  treatment  of  epigastric  hernia  is  surgical. 

1  Charles  D.  Aaron,  Stomach  Disturbances  Caused  by  Hernia  of  the  Linea  Alba 
in  the  Epigastrium,  Medical  Record,  November  20,  1897. 


CHAPTER  XXX. 

GASTROENTEROPTOSIS. 

Gastroptosis ;  Enteroptosis;  Splanchnoptosis;  Coloptosis; 
Nephroptosis;  Hepatoptosis ;  Splenoptosis;  Cecum  Mobile; 
Redundant  Sigmoid. 

Gastroptosis  (a  term  for  which  we  are  indebted  to  Glenard) 
is  so  frequently  complicated  with  displacement  of  the  intestine 
and  other  abdominal  organs  that  it  may  be  considered  conveniently 
under  the  heading  of  Gastroenteroptosis.  Separate  names  have 
been  given  to  the  downward  displacement  of  abdominal  viscera, 
among  which  we  have  gastroptosis,  referring  to  downward  dis- 
placement of  the  stomach;  coloptosis,  or  downward  displacement 
of  the  colon;  hepatoptosis,  splenoptosis,  nephroptosis,  enteroptosis, 
referring  respectively  to  downward  displacement  of  the  liver, 
spleen,  kidney,  and  intestine.  The  etiology  and  clinical  mani- 
festations of  these  conditions,  as  well  as  their  treatment,  are  so 
similar  that  they  may  be  considered  with  advantage  together. 

Etiology.— Gastroenteroptosis  is  a  condition  frequently  met  with 
in  patients  who  consult  a  physician  in  regard  to  digestive  disturb- 
ances. It  is  a  disease  of  comparatively  young  adult  life,  appear- 
ing soon  after  puberty,  but  is  occasionally  met  with  in  patients  over 
fifty  years  of  age.  Females  are  particularly  disposed  to  gastro- 
enteroptosis. 

Forms. — From  the  viewpoint  of  etiology  two  different  forms  of 
gastroenteroptosis  are  to  be  distinguished.  The  first  is  the  result 
of  causes  acting  mechanically,  the  principal  etiologic  factors  being 
improper  modes  of  dress,  traumatism,  frequent  childbirth,  and 
tight  lacing;  all  these  causes  are  aided  by  poor  nutrition  and  severe 
physical  toil.  This  form  of  gastroenteroptosis  comprises  a  com- 
paratively small  number  of  cases.  Frequent  pregnancies,  by  bring- 
ing about  a  condition  of  relaxation  of  the  abdominal  wall  and 
diastasis  of  the  recti  muscles,  producing  thereby  a  pendulous 
abdomen,  are  responsible  for  many  of  these  cases  of  gastroenterop- 
tosis. It  has  been  shown  repeatedly  that  tight  lacing  is  productive 
of  downward  dislocation  of  the  intestine.  The  removal  of  large 
abdominal  tumors  and  frequent  paracenteses  in  order  to  free  the 
abdomen  of  ascitic  fluid,  are  also  etiologic  factors.  Organic  diseases 
in  general  may  likewise  lead  to  ptosis  of  the  stomach.  The  causal 
relation  between  trauma  of  the  abdomen  and  displacement  of  the 
kidnev  is  well  known. 


558 


GASTROENTEROPTOSIS 


The  second  form  of  gastroenteroptosis  is  due  to  a  constitutional 
hereditary  predisposition.  Thanks  to  the  researches  of  Stiller, 
more  is  understood  of  this  variety  of  downward  displacement 
than  formerly,  and  his  views  are  now  almost  universally  accepted. 
According  to  this  writer,  in  90  per  cent,  of  cases  of  gastroenterop- 
tosis the  abnormal  position  of  the  abdominal  viscera  is  quite  a 

distinct  form  of  the  physical  confor- 
mation. Stiller  calls  it  "  habitus  en- 
teroptoticus"  or  "asthenia  universalis 
congenita"  (Fig.  87) .  Patients  suffering 
from  this  weakness  and  from  the 
characteristic  bodily  form  are  apt  to 
develop  into  neurasthenics.  The  con- 
dition of  gastroenteroptosis  is  often 
complicated  with  gastric  and  intestinal 
atony  and  nervous  dyspepsia.  A  well- 
marked  case  of  habitus  enteroptoticus 
presents  a  complex  of  symptoms, 
namely,  those  of  gastroenteroptosis, 
gastric  atony,  and  nervous  dyspepsia. 
This  complex  of  symptoms  has  been 
designated  general  asthenia.  These 
three  affections  are  not  always  pres- 
ent, however,  in  the  same  degree  of 
intensity;  gastroenteroptosis  gives  rise, 
as  a  rule,  to  the  most  pronounced 
symptoms.  The  mechanical  causes 
mentioned  above  would  not,  in  all 
probability,  give  rise  to  gastroenterop- 
tosis were  the  patient  not  predisposed 
to  this  condition  by  the  habitus  enter- 
optoticus. Hence  it  may  be  concluded 
that  gastroenteroptosis  from  purely 
mechanical  causes  is  a  rare  condition. 

Pathology. — Gastroptosis  does  not 
imply  a  dropping  or  downward  dis- 
placement of  the  entire  stomach. 
On  account  of  the  attachment  of  the 
stomach  at  the  cardia  it  is  impossible 
for  the  displacement  to  be  complete; 
when  we  speak  of  gastroptosis  a  descent 
of  the  pylorus  and  that  part  of  the  stomach  directly  in  front  of  the 
vertebral  column  is  implied.  With  the  downward  displacement  of 
the  pylorus  there  is  likely  to  be  a  stretching  of  the  stomach  from 
the  cardiac  orifice  toward  the  pylorus.  This  forms  the  so-called 
"water-trap"  stomach  (Plate  XIII,  Fig.  1).  Several  abnormal 
conditions  enter  into  the  development  of  both  gastroptosis  and 


Fig.  87. — Habitus  enteropto- 
ticus (asthenia  universalis  con- 
genita). 


PATHOLOGY  559 

enteroptosis.  The  ligaments  and  mesenteries  may  become  relaxed, 
thus  permitting  a  displacement  of  the  organs  attached  to  them;  or 
the  intra-abdominal  equilibrium  may  be  disturbed  by  alteration  of 
the  intra-abdominal  pressure  upon  which  it  depends,  and  gastro- 
enteroptosis  results. 

Part  of  the  duodenum  as  well  as  the  entire  large  intestine  may 
be  displaced.  The  mesenteries  easily  stretch  to  meet  this  condi- 
tion. Certain  mesenteric  supports  of  the  intestine  are  more  rigid 
than  others  and  will  not  yield  to  the  displacement.  The  ligaments 
at  the  hepatic  and  splenic  flexures  of  the  colon  do  not  yield  readily, 
and  under  traction  these  parts  become  abnormally  kinked,  simu- 
lating stenosis.  In  this  condition  the  intestinal  contents  pass 
through  with  great  difficult}'.  The  distal  end  of  the  duodenum 
is  fixed  by  a  strong  ligamentous  band  to  the  diaphragm.  The 
duodenum,  being  fixed,  cannot  move  down,'  while  all  the  other 
abdominal  organs  glide  down  during  gastroenteroptosis.  Hence 
the  transverse  segment  of  the  duodenum  becomes  compressed  by 
the  superior  mesenteric  artery,  inducing  duodenal  dilatation 
(Plate  XVII,  Fig.  2,  opposite  page  144).  The  downward  dis- 
placement of  the  stomach  tends  to  produce  stenosis  of  the  fixed 
part  of  the  duodenum,  with  chronic  dilatation.  The  symptoms  of 
chronic  dilatation  of  the  duodenum  are:  persistent  or  recurring 
vomiting  of  bile,  pain  referred  to  the  right  hypochondrium,  con- 
stipation, headache,  and  nervous  symptoms.  In  marked  cases 
starvation  with  acidosis  develops  and  leads  to  a  fatal  termination. 

The  transverse  colon,  owing  to  its  ligamentary  connection  with 
the  stomach,  is  most  frequently  involved.  Any  material  degree  of 
gastroptosis  causes  coloptosis  (Plate  XVIII,  Fig.  1,  opposite  page 
144),  since  the  transverse  colon  is  made  to  descend.  The  hepatic 
flexure  suffers  in  gastroenteroptosis,  because  as  the  stomach  passes 
downward  it  forces  the  transverse  colon  before  it  and  hence  makes 
more  and  more  acute  the  hepatic  flexure  (Plate  XVIII,  Fig.  3). 
However,  since  the  hepatic  flexure  is  usually  obtuse  or  rectangular 
in  outline,  it  is  seldom  drawn  so  tightly  by  the  hepatic  ligament 
as  to  cause  very  pronounced  stenosis.  The  splenic  flexure  forms 
normally  an  acute  angle;  it  is  a  distinctive  anatomic  provision  for 
fixing  the  colon  to  the  costal  wall.  In  gastroenteroptosis  the 
splenic  flexure  is  dragged  on  and  its  angle  made  more  acute  (Plate 
XVIII,  Fig.  2).  The  stomach  drags  the  middle  of  the  transverse 
colon  downward,  which  tightens  the  hepatic  and  splenic  flexures 
in  direct  proportion  to  the  extent  of  the  gastroptosis  (Fig.  88). 

A  prolapsed  cecum  may  pull  on  the  end  of  the  ileum,  while  the 
short,  firm  mesentery  of  the  latter  acts  as  a  counter-pull,  inducing 
the  Lane  kink  of  the  ileum  (Fig.  89,  b).  The  dropping  of  the 
lower  coils  of  the  ileum  will  cause  the  same  kink.  This  kink  does 
not^occur  if  the  abdominal  viscera  are  in  their  normal  position. 
The^form  of  attachment  of  the  cecum  makes  it  freely  movable. 


560 


GASTROENTEROPTOSIS 


An  abnormal  mobility  of  the  cecum  of  two  to  four  inches  has  been 
emphasized  by  Wilms  (see  Cecum  Mobile,  p.  146) .  Occasionally  the 
cecum  fails  to  rotate;  in  this  congenital  malformation  the  terminal 
coils  of  the  ileum  are  posterior  to  the  cecum  (see  page  770). 

The  sigmoid  flexure,  the  most  movable  part  of  the  large  intestine, 
is  likewise  liable  to  undergo  important  positional  changes.  Just 
as  its  length .  and  lumen  may  experience  widely  varying  deviations 


Fig.  88. — Descent  of  transverse  colon,  acute  angulation  at  the  splenic  flexure,  with 
adhesion  and  angulation  of  the  sigmoid  flexure.     (Tuttle.) 

from  the  normal  (Hirschsprung's  disease),  so  may  its  position  and 
loop-formation  present  equally  varying  abnormalities  (redundancy). 
Glenard,  the  apostle  of  gastroenteroptosis,  describes  a  condition 
which  he  calls  phrenoptosis — that  is,  downward  displacement 
of  the  diaphragm.  He  considers  it  responsible  for  the  condition 
known  as  movable  heart  or  cardioptosis,  though  itself  merely  an 
episode  of  the  general  tendency  to  ptosis. 


PATHOLOCY 


561 


At  certain  points  kinks  are  apt  to  occur  when  there  is  a  dropping 
of  the  stomach  and  intestine  (Fig.  89).  These  may  all  be  easily 
made  out  by  the  use  of  bismuth  and  the  Roentgen  ray  (see  Chapter 
V).  From  above  downward,  kinking  may  occur  at  the  junction 
of  the  duodenum  and  jejunum  (Fig.  89,  a),  at  the  distal  end  of 
the  ileum  (Fig.  89,  b),  at  the  hepatic  flexure  (Fig.  89,  c),  at  the 
splenic  flexure  (Fig.  89,  d),  and  at  the  sigmoid  flexure  (Fig.  89,  e). 
Should  pericolic  membranes  form  around  these  kinks,  an  actual 
obstruction  may  occur. 

During  embryonic  evolution  certain  membranes  form  and  dis- 
appear. In  certain  instances,  for  some  untold  reason,  these  tem- 
porary membranes  remain  as  a  thin  veil  (Jackson's),  containing 


Fig.  89. — Kinks  of  the  intestine:  a,  duodenum;  b,  ileum;  c,  hepatic  flexure;  d,  splenic 
flexure;  e,  sigmoid  flexure. 

small  linear  vessels.  These  pericolic  membranes  are  not  patho- 
logic; they  do  not  do  any  harm.  Should  an  alimentary  toxemia 
develop,  however,  pericolitis  results  and  the  membranes  become 
thickened  and  obstructive.  This  pathologic  change  often  occurs 
in  gastroenteroptosis,  producing  angulations,  kinks,  adhesions, 
bands,  narrowing,  and  chronic  intestinal  stasis  (see  Chapter 
XXXIX). 

Recent  experimental  work  by  Keith  and  his  discovery  of  nodal 
tissue  in  the  intestine  (see  page  64),  explaining  the  mechanism  of 
intestinal  movements,  sheds  a  new  light  upon  the  causation  of 
intestinal  stasis.  Notable  quantities  of  this  "nodal  and  conduct- 
ing" tissue  were  found  in  the  region  of  the  cardia  of  the  stomach, 
36 


562  GASTROENTEBOPTOSIS 

where  it  initiates  gastric  movements;  near  the  ampulla  of  Vater,  to 
control  the  movements  of  the  pylorus  and  duodenum;  a  lesser 
quantity  near  the  beginning  of  the  jejunum,  exercising  the  same 
function  over  the  greater  portion  of  the  remaining  small  intestine; 
in  the  region  of  the  ileocolic  valve,  to  control  the  lower  ileum  and 
proximal  portion  of  the  colon;  and  also  in  the  transverse,  descend- 
ing and  iliac  colon,  and  in  the  rectum.  Not  only  do  the  anatomic 
sites  and  the  demonstrable  physiologic  functions  of  these  "nodes" 
explain  the  normal  movements  of  the  intestine,  but  it  is  obvious 
that  a  perversion  of  the  function  of  any  one  of  them  is  capable 
of  giving  rise  to  an  inhibition  of  the  forward  progress  of  the  intes- 
tinal contents,  with  resulting  intestinal  stasis.  In  the  establish- 
ment of  this  as  the  physiologic  explanation  of  the  mechanism  of  the 
production  of  intestinal  stasis,  Keith  was  able  to  demonstrate  the 
presence  of  definite  fibrotic  and  degenerative  changes  in  this  nodal 
tissue  in  segments  of  the  intestine  removed  for  the  relief  of  chronic 
intestinal  stasis  (see  page  696). 

Symptoms. — Many  patients  with  habitus  enteroptoticus  which 
has  developed  into  pronounced  gastroenteroptosis  do  not  experi- 
ence any  troublesome  symptoms  whatever.  The  same  may  be  said 
of  those  whose  gastroenteroptosis  is  the  result  of  purely  mechanical 
causes.  On  the  other  hand,  many  patients  have  been  relieved 
of  the  distressing  symptoms  accompanying  gastroenteroptosis 
without  correction  of  the  anatomic  displacements.  It  may  be 
inferred  from  this  that  gastroenteroptosis  in  itself  does  not  produce 
any  marked  disturbance  or  discomfort  to  the  patient.  The  con- 
stitutional neurasthenia  of  enteroptotics  is  responsible  for  a  great 
many  of  the  subjective  symptoms  ascribed  to  gastroenteroptosis 
itself.  The  displacement  merely  aggravates  the  neurasthenic 
effects,  or  perhaps  in  some  instances  initiates  them  by  the  continu- 
ous traction  of  the  displaced  viscera  on  the  mesenteries,  thus 
placing  the  abdominal  sympathetic  nervous  system  in  a  condition 
of  continued  reflex  irritation.  Atony  of  the  stomach  and  intestine, 
a  frequent  accompaniment  of  well-marked  ptosis  of  these  organs, 
is  productive  of  many  untoward  symptoms.  Patients  complain 
of  a  variety  of  nervous  manifestations,  such  as  lassitude,  dull  head- 
ache, inability  to  work,  mental  depression,  and  general  weakness. 
The  gastric  symptoms  consist  of  pressure,  fulness,  nausea,  and 
belching;  occasionally  pain  is  felt  in  the  region  of  the  stomach. 
Indications  of  nervous  dyspepsia  (see  Chapter  XIX)  are  also  in 
evidence  as  burning  sensations  in  the  stomach,  hyperacidity,  and 
vague  discomforts  after  eating.  The  appetite  is,  as  a  rule,  poor, 
though  on  rare  occasions  patients  have  ravenous  appetites.  Gas- 
troenteroptosis is  often  accompanied,  in  women  particularly,  by 
severe  backaches.  These  enteroptotic  conditions  are  closely  related 
to  persistent  constipation.  It  is  easily  intelligible,  and  has  also 
been  clearly  pointed  out,  that  in  consequence  of  these  conditions, 


SYMPTOMS  563 

especially  in  the  presence  of  constipation,  catarrh  may  occur, 
showing  a  predilection  for  the  flexures  and  the  sigmoid.  In  a 
clinical  respect  it  is  therefore  sufficient  to  refer  the  reader  to  the 
chapter  on  Constipation  (Chapter  XXXVII). 

Objective  Symptoms. — The  objective  symptoms  in  cases  of  well- 
marked  habitus  enteroptoticus  are  very  characteristic.  The 
patients,  as  a  rule,  are  tall  in  stature,  with  long  arms,  thin  neck, 
narrow  elongated  thorax,  long  flat  abdomen,  and  a  predisposi- 
tion to  flat-foot  and  lordosis.  Children  are  able  to  subluxate  the 
first  phalanx  of  each  finger  on  the  metacarpal  of  the  preceding  one. 
The  habitus  enteroptoticus  impresses  the  observer  as  being  similar 
to  the  habitus  phthisicus.  The  bony  structure  is  slight,  the  muscles 
wreak,  and  there  is  a  marked  diminution  in  the  adipose  tissue  which 
gives  grace  to  the  physical  appearance.  Enteroptotic  patients, 
as  a  rule,  look  pale  and  give  the  impression  of  being  ill.  Their 
spirits  are  usually  depressed.  Characteristic  alterations  of  the 
thorax  belong  also  to  the  habitus  enteroptoticus:  the  thorax  is 
long  and  narrow  and  the  shoulders  slant  downward.  The  epi- 
gastric angle  is  markedly  acute.  The  intercostal  spaces  are  sunken 
and  the  abdominal  walls  are  thin  and  flaccid.  The  distance  between 
the  umbilicus  and  the  ensiform  cartilage  is  greater  than  in  a  normal 
person.  The  Lenhoff  index — the  distance  in  centimeters  from  the 
episternal  notch  to  the  symphysis  pubis,  multiplied  by  100,  and 
divided  by  the  greatest  circumference  of  the  abdomen — is  over  80 
.centimeters.  The  epigastric  region  is  sunken  when  the  patient 
stands  erect.  The  abdomen,  how*ever,  below  the  navel  protrudes 
in  consequence  of  the  weight  of  the  descended  abdominal  viscera 
(Fig.  87).  There  are  frequently  found  broad  spaces  between  the 
recti  muscles  (diastasis).  During  respiration  the  lesser  curvature 
of  the  stomach  will  be  discerned  at  times  and  may  be  outlined 
beneath  the  thin  abdominal  wall.  A  special  feature  of  the  habitus 
enteroptoticus  is  a  movable  tenth  rib,  which  is  shortened  and  easily 
displaced  in  consequence  of  the  absence  of  the  cartilaginous  attach- 
ment. This  fluctuating  rib,  knowrn  as  Stiller's  sign,  is  present  in 
about  70  to  80  per  cent,  of  all  cases  of  gastroenteroptosis.  In 
female  patients  it  is  possible  at  times  to  palpate  the  abdominal 
aorta  and  to  ascertain  strong  pulsation  on  but  slight  pressure. 
The  ease  with  wmich  the  abdominal  aorta  may  be  palpated  is  a 
sign  of  neurasthenia,  and  this  condition  is  due  to  a  dilatation  or 
paralysis  of  the  vessel  wall  brought  about  by  reflex  causes.  The 
celiac  plexus,  which  is  located  on  the  anterior  surface  of  the  abdom- 
inal aorta  in  the  epigastric  region,  is  not  infrequently  very  sensitive 
to  pressure;  this  condition  is  also  considered  suggestive  of  neur- 
asthenia. 

A  high  pulse-rate  when  the  patient  is  standing  is  the  rule  in  cases 
of  gastroenteroptosis.  The  difference  between  the  pulse-rates  in 
the  standing  and  recumbent  positions  is  an  index  of  the  intensity 


564 


GASTROENTEROPTOSIS 


of  the  abdominocardiac  reflex.  The  abnormal  acceleration  of  the 
pulse-rate  is  supposed  to  be  due  to  the  dragging  of  the  stomach  and 
intestine  on  the  fibers  of  the  vagus. 

Diagnosis. — Gastroentero ptosis  is  recognizable  by  means  of  infla- 
tion, auscultatory  percussion  (Benedict),  and  transillumination. 
The  value  of  Roentgen-ray  examination  lies  in  its  detection  of  the 
true  state  of  affairs  (see  Chapter  V).  The  diagnosis  of  all  these 
dislocations  can  be  absolutely  confirmed  by  this  method  of 
examination. 


Fig.  90. — Locating  the  point  of  tenderness. 


In  cases  of  gastroenteroptosis,  deep  continuous  pressure  with 
the  ends  of  the  fingers  over  the  celiac  plexus  in  the  epigastrium 
will  induce  pain  (Fig.  90).  The  point  of  sensibility  varies  in 
different  individuals.  To  locate  it,  the  cooperation  of  an  assist- 
ant is  necessary.  With  the  patient  standing,  the  physician  applies 
his  fingers  in  a  series  of  deep  pressures  until  the  point  of  greatest 
tenderness  is  found.  The  fingers  are  held  at  this  point.  The 
nurse  then  takes  a  position  behind  the  patient,  passes  both  arms 
about  him  so  that  the  hands,  meeting  in  front,  rest  on  the  hypo- 
gastrium,  and  lifts  the  abdomen  in  its  entirety  (Fig.  91).  This 
relieves  the  epigastric  pain  at  once,  despite  the  great  pressure 


n/ACxosis 


565 


exerted  by  the  physician  at  the  point  of  tenderness.  \\  lien, 
however,  the  nurse  allows  the  patient's  abdomen  to  drop  to  its 
former  position,  the  dee])  pressure  continuing,  the  pain  reappears 
(Fig.  90). 

This  sign  is  constant  in  gastroenteroptosis.1  In  organic  disturb- 
ances, such  as  gastric  ulcer,  carcinoma,  etc.,  the  pain  under  pressure 
continues  even  when  the  abdomen  is  lifted. 

The  pain  on  pressure,  relieved  by  lifting  the  abdomen,  is  an 
objective  sign  which  I  believe  to  be  reliable  in  the  diagnosis  of 
gastroenteroptosis. 


Fig.  91. — Nurse  lifting  abdomen. 

Nephroptosis. — Displacement  of  the  kidneys  is  frequently  found 
in  gastroenteroptosis — is  often,  indeed,  a  pathognomonic  sign. 
The  right  kidney  is  usually  the  one  affected.  The  terms  movable 
kidney,  dislocated  kidney,  wandering  kidney,  floating  kidney, 
prolapsed  kidney  and  nephroptosis  have  been  applied  to  a  variety 
of  renal  displacements.  Movable  kidney  is  said  to  be  five  or  six 
times  more  frequent  in  women  than  in  men.  Both  kidneys  movable 
is  a  condition  observed  almost  exclusivelv  in  women.     Inasmuch 


. l  Charles  D.  Aaron,  A  Diagnostic  Sign  of  Gastroenteroptosis,  The  Archives  of 
Diagnosis,  New  York,  April,  1917. 


566  GASTROENTEROPTOSIS 

as  movable  kidney  implies  gastroenteroptosis,  it  is  of  the  utmost 
importance  to  diagnosticate  the  condition.  The  diagnosis  is  easily 
made  by  palpation.  The  correctness  of  the  result  depends,  of 
course,  on  the  degree  of  technical  skill  applied  in  manipulation. 
Every  physician  can  acquire  the  art  of  palpation  by  careful  study 
and  practice.  One  hand  is  placed  on  the  back,  over  the  lumbar 
region,  and  the  other  on  the  abdomen;  bimanual  palpation  is 
always  necessary.  The  clothing  should  be  removed  and  the  pal- 
pating hands  brought  in  direct  contact  with  the  skin.  The  abdo- 
men of  the  patient  should  be  relaxed  as  completely  as  possible 
before  the  examination.  The  hands  of  the  physician  should  be 
placed  flat,  one  on  the  back  and  one  on  the  abdominal  wall.  Severe 
pressure  with  the  fingers  should  be  avoided.  It  is  best  to  begin 
softly,  allowing  the  pressure  to  become  gradually  greater.  The 
palpating  hands  should  be  warm,  since  cold  hands  cause  con- 
traction of  the  abdominal  muscles  and  prevent  deep  manipulation. 
In  cases  where  the  tension  of  the  abdominal  walls  is  too  great, 
chloroform  narcosis  may  be  employed.  This  is,  however,  rarely 
necessary.  The  physician  may  often  feel  the  kidney  slide  from 
under  his  hands;  its  smooth  surface  and  distinct  outline  are  very 
characteristic.  In  palpating  for  movable  kidney  the  patient  is 
placed  in  three  different  positions : 

1.  Standing  while  the  manipulator  sits  on  a  chair. 

2.  Lying  on  the  back  while  the  manipulator  sits  on  the  edge  of 
the  couch. 

3.  Lying  on  either  side,  according  to  which  kidney  is  being 
palpated,  while  the  manipulator  sits. 

First  position  (Fig.  92 ) .  This  is  the  most  important  position  for 
palpating  a  movable  kidney,  since  it  permits  the  maximum  dis- 
placement, and  the  kidney  is  therefore  easily  felt.  Begin  by 
superficial  pressure,  and  later  use  deeper  manipulation.  Super- 
ficial pressure  reveals  the  resistance  in  the  abdomen  while  the 
abdominal  muscles  support  the  viscera,  and  the  hands  soon  differ- 
entiate between  the  natural  and  the  artificial  support  of  these 
muscles.  Deep  palpation  in  this  position  is  of  great  importance, 
since  frequently  the  kidney  can  be  held  in  the  hand.  With  one 
hand  on  the  lumbar  region  the  whole  abdomen  must  be  explored 
with  the  other,  as  a  movable  kidney  may  be  displaced  anywhere 
from  its  normal  position,  even  as  low  as  the  symphysis  pubis. 
The  peculiar  shape  of  the  kidney,  its  smooth  characteristic  feel, 
and  the  way  it  slips  from  the  hand  under  the  ribs  will  make  it 
easily  recognizable. 

T\  nen  a  kidney  is  in  normal  position  it  moves  slightly  during 
respiration.  A  normally  located  kidney  cannot  be  palpated, 
^lien  one-third  of  the  kidney  can  be  palpated  the  condition  is 
spoken  of  as  displacement  of  the  first  degree;  when  one-half  is 
palpable,    displacement   of   the   second   degree;   when   the   whole 


DIAGNOSIS 


567 


kidney  is  palpable,  displacement  of  the  third  degree.  The  same 
procedure  should  be  followed  out  in  palpating  the  kidney  on  either 
side.  On  account  of  their  close  attachment  to  the  diaphragm, 
the  liver  and  the  gall  bladder  move  during  respiration.  Care  should 
be  exercised  lest  they  be  mistaken  for  the  kidney. 

Second  position  (Fig.  93).  In  this  position  the  patient  lies  on 
his  back,  with  the  shoulders  raised  and  the  legs  slightly  flexed. 
One  hand  of  the  physician  is  placed  on  the  lumbar  region  and  the 
other  flat  on  the  abdomen,  below  the  costal  margin,  along  the 


Fig.  92. — First  position  for  palpating  movable  kidney. 


outer  border  of  the  rectus  muscle.  The  patient  should  be  in- 
structed to  take  a  deep,  slow  inspiration,  when  the  kidney,  if 
movable,  may  be  felt  between  the  hands.  The  kidney  naturally 
drops  back  to  its  normal  position  when  the  patient  lies  on  his 
back,  for  which  reason  it  is  wise  to  resort  to  other  positions  in  order 
to  confirm  the  diagnosis.  Usually  mobility  of  the  third  degree  is 
best  made  out  with  the  patient  in  this  position. 

Third  position  (Fig.  94).    The  patient  should  lie  upon  the  side 
opposite  to  that  to  be  explored.     The  shoulders  should  be  thrown 


568 


GASTROENTEROPTOSIS 


forward  and  the  thighs  slightly  flexed.  The  physician  should  sit 
on  the  edge  of  the  couch.  One  hand  over  the  lumbar  region  and  the 
other  over  the  abdomen  will  bring  the  kidney  between  the  two 
hands.  To  bring  it  lower,  should  it  be  movable,  the  patient  is 
instructed  to  take  a  deep  inspiration,  when  the  diaphragm  will 


Fig.  93. — Second  position  for  palpating  movable  kidney. 

force  it  downward;  then  during  expiration  it  can  be  held  firmly 
between  the  hands.  The  slightest  relaxation  of  the  pressure  of 
the  hand  will  permit  the  kidney  to  slip  away  from  between  the 
fingers,  which  is  characteristic  of  no  other  organ. 

Hepatoptosis. — Hepatoptosis,  dislocation  of   the  liver,  is  of  fre- 
quent occurrence,  and  when  overlooked  may  give  rise  to  diagnostic 


Fig.  94. — Third  position  for  palpating  movable  kidney. 

error.  Hepatoptosis  originates  from  the  same  general  causes  as 
gastroenteroptosis.  Glenard  found  in  two-thirds  of  his  cases  of 
hepatoptosis  that  nephroptosis  also  was  present.  Hepatoptosis 
with  hepatic  colic  is  frequently  mistaken  for  cholelithiasis  (see 
page  605). 


TREATMENT  569 

Splenoptosis. — Abnormal  positions  of  the  spleen  arc  rarely  found, 
except  occasionally  when  it  is  enlarged. 

Prognosis.— The  prognosis  for  permanent  replacement  of  the 
displaced  organs  is,  as  a  rule,  not  good.  A  ptotic  stomach  or 
intestine  remains  so.  The  distressing  symptoms  accompanying  the 
condition  may,  however,  be  entirely  removed  or  greatly  amelio- 
rated, so  that  patients  with  congenital  habitus  enteroptoticus  may 
pass  the  remainder  of  their  lives  in  comparative  comfort.  We  can- 
not give  these  patients  normal  mesenteries,  but  we  can  give  them 
normal  function. 

Prophylaxis. — Prophylaxis,  so  far  as  the  mechanical  causes  of 
gastroenteroptosis  are  concerned,  consists  in  keeping  patients  in 
bed  for  a  sufficient  time  after  parturition,  reinforcing  the  abdominal 
muscles  by  abdominal  bandages,  and  strengthening  the  muscles 
by  exercise  and  massage.  By  these  measures  much  of  the  muscu- 
lar relaxation  of  the  abdominal  wall  following  childbirth  may  be 
avoided.  Properly  fitting  corsets  are  a  valuable  prophylactic 
agency.  The  habitus  enteroptoticus  may  sometimes  be  recognized 
in  young  subjects  by  their  peculiar  physique  and  weak  stomach. 
In  such  subjects  marked  departure  from  the  normal  may  be 
retarded  by  suitable  preventive  treatment  in  spite  of  the  existing 
predisposition. 

Treatment. — The  treatment  of  gastroenteroptosis  should  be 
directed  toward  improvement  of  the  general  nutrition,  in  order  to 
counteract  the  neurasthenia  and  to  strengthen  the  muscles  of  the 
abdominal  walls. 

Patients  who  are  poorly  nourished  must  be  well  fed.  The 
diet  should  be  as  nutritious  as  possible;  it  should  contain  a  large 
proportion  of  fat.  Milk,  cream  and  butter  are  among  the  most 
suitable  articles  of  food  for  this  condition.  The  nutrition  must 
be  governed  almost  entirely  by  the  requirements  of  the  individual 
case.  The  motor  and  secretory  powers  of  the  stomach  should 
always  be  considered  in  prescribing  diet. 

Hyperalimentation. — Sometimes  it  is  necessary  to  resort  to  "  forced 
feeding,"  by  which  we  mean  hyperalimentation.  It  is  well,  how- 
ever, before  attempting  systematic  hyperalimentation,  to  ascertain 
the  actual  powers  of  assimilation  of  the  patient.  In  determining 
the  status  of  a  patient's  nutrition  two  factors  must  be  borne  in 
mind — first,  the  condition  of  the  protoplasm  (muscles  and  blood) ; 
and  secondly,  the  amount  of  fat  present.  The  protoplasm  is 
estimated  from  the  muscular  mass.  A  person  with  weak  muscles, 
as  a  rule,  suffers  from  deficiency  in  nutrition.  An  attempt  should 
be  made  to  strengthen  the  weak  muscles  of  these  patients  by 
hyperalimentation,  and  thus  bring  about  an  improvement  in  the 
quality  of  the  blood. 

Fat  should  constitute  18  to  20  per  cent,  of  the  total  body  weight 
of  the  adult  male,  and  25  to  28  per  cent,  of  the  weight  of  the  female. 


570  GASTROENTEROPTOSIS 

It  is  necessary,  then,  for  the  physician  to  estimate  as  well  as  he 
can  the  quantity  relation  between  adipose  tissue  and  muscle.  In 
certain  diseases  the  presence  of  what  might  be  termed  an  excess 
of  fat  is  not  an  undesirable  feature,  while  in  other  ailments  it  is 
desirable  that  the  amount  of  fat  be  less  than  in  the  normal  indi- 
vidual. In  gastroenteroptosis  and  neurasthenia  it  has  been  found 
advisable  to  keep  the  nutrition  up  to  the  highest  possible  point, 
and  that  patients  do  better  when  the  amount  of  adipose  tissue  is 
above  the  indicated  percentage  for  their  body  weight.  In  pursuing 
a  course  of  hyperalimentation  it  is  an  advantage  to  know  the 
quantity  of  nutriment  required  by  each  patient  in  order  to  maintain 
his  particular  body  weight.  The  following  values  have  been 
calculated  for  this  purpose. 
The  patient  requires: 

Calories  per  kilogram  body- 
weight  for  the  twenty-four  hours. 

1.  When  kept  in  bed 30  to  35 

2.  When  confined  to  the  room 32  to  35 

3.  When  employed  at  light  labor 35  to  40 

4.  When  employed  at  moderate  physical  labor     .      .  40  to  45 

5.  When  employed  at  hard  labor 45  to  50 

A  diet  corresponding  to  the  above  table  is  designated  a  "sus- 
taining diet."  Such  a  regimen,  it  will  be  seen,  will  vary  in  the 
same  individual,  depending  upon  the  question  of  rest  or  physical 
activity. 

Before  beginning  the  so-called  hyperalimentation  cure  it  is 
necessary  to  ascertain  the  sustaining  diet  for  the  patient.  This 
may  be  easily  accomplished  by  referring  to  the  standard  tables  of 
food  substances,  which  give  the  exact  percentages  of  protein,  fat 
and  carbohydrates  in  the  food,  with  the  caloric  value  of  each  (see 
Chapters  VI  and  VII).  The  calculation  of  the  food  value  of  dishes 
complex  in  composition  should  be  entered  upon  with  great  care. 
An  exact  knowledge  of  the  composition  and  food  value  of  soups 
and  farinaceous  foods  is  necessary  if  the  physician  is  to  avoid  error 
in  dietary  prescription.  When  it  is  desired  to  ascertain  the  exact 
condition  of  undernutrition  of  a  patient,  the  food  should  be  care- 
fully weighed  and  estimated  in  calories  and  the  result  compared  with 
the  sustaining  diet  of  that  particular  patient.  Should  the  amount 
of  food  ordinarily  ingested  by  the  patient  be  less  than  the  sustain- 
ing diet,  the  condition  is  one  of  undernutrition. 

Hyperalimentation  consists  in  the  ingestion  of  certain  quanti- 
ties of  nutritive  material  in  excess  of  the  amount  of  the  sustaining 
diet — the  intention  being,  of  course,  to  increase  the  weight  of  the 
patient.     This  added  nutriment  is  known  as  the  food  surplus. 

Von  Xoorden  has  calculated  the  probable  increase  in  weight 
during  a  course  of  hyperalimentation  as  follows: 

Daily  increase  in  food.  Weekly  increase  in  weight. 

500  to    800  calories  yield 600  to  1000  Gm. 

800  to  1200  calories  yield 800  to  1200  Gm. 

1200  to  1800  calories  yield 1200  to  2000  Gm. 


TECHNIC  OF  NUTRITION  571 

Of  the  total  number  of  calories  represented  in  the  added  food  in 
a  course  of  hyperalimentation,  8  per  cent,  is  used  up  for  purposes 
of  digestion  and  assimilation;  about  4  per  cent,  is  lost  in  the  feces; 
and  10  per  cent,  is  stored  up  as  protein.  The  remaining  78  per 
cent,  is  assimilated  as  fat. 

One  of  the  best  means  for  increasing  the  amount  of  muscle  tissue 
is  systematic  muscular  exercise.  If  the  patient  can  be  persuaded 
to  take  regular  muscular  exercise  during  the  food  cure,  a  marked 
increase  in  flesh  will  result.  It  has  been  demonstrated  that  mus- 
cular activity  develops  the  muscles.  This  would  seem  to  be  in 
opposition  to  the  food  cure  as  outlined  by  those  who  first  made 
use  of  it.  Weir  Mitchell  and  Playfair  insisted  upon  having  their 
patients  maintain  the  recumbent  position.  But  one's  cases  must 
be  differentiated.  Some  are  too  weak  for  exercise,  or  the  condition 
of  the  digestive  system  may  require  absolute  quietude. 

It  is,  moreover,  advisable  that  every  patient  be  put  to  bed  for 
the  first  eight  days  at  least  when  undergoing  the  so-called  food 
cure.  This  will  accustom  him  to  the  regular  administration  of 
food  and  likewise  reduce  the  combustion  processes  to  the  lowest 
possible  degree.  The  radiation  of  heat  is  diminished  and  its 
retention  favored  by  complete  rest.  Many  writers,  however, 
prefer  that  patients  should  undergo  active  muscular  movement 
as  soon  as  there  are  signs  of  increase  in  weight  during  the  first 
week.  The  slight  loss  of  weight  which  may  result  from  this  mus- 
cular exercise  is  soon  compensated  by  the  marked  increase  in  appe- 
tite which  follows  the  bodily  activity.  The  muscular  exercise 
should  be  so  arranged  as  to  avoid  undue  fatigue.  The  condition 
of  a  patient  after  a  course  of  hyperalimentation  combined  with 
muscular  exercise  will  be  much  more  vigorous  than  if  the  exercise 
had  been  omitted. 

Technic  of  Nutrition. — The  diet  should  not  consist  of  protein 
substances  alone.  Their  caloric  value  is  more  than  offset  by  the 
difficulty  with  which  they  are  assimilated.  From  12  to  15  per 
cent,  of  the  energy  afforded  by  a  protein  diet  is  lost  in  digestion, 
as  compared  with  the  8  per  cent,  waste  from  a  mixed  diet.  Protein 
increases  combustion.  In  the  sustaining  diet  the  daily  quantity 
of  protein  is  about  100  Gm.;  in  hyperalimentation  it  should  be 
between  100  and  120  Gm.  This  amount  of  protein  is  found  in  the 
ordinary  mixed  diet.  Protein  may  be  administered  in  any  form, 
such  as  the  lean  varieties  of  meat,  fish,  or  fowl.  Fat  has  the  dis- 
advantage, as  compared  with  lean  meat,  of  more  quickly  satisfy- 
ing the  appetite  or  exciting  a  distaste  for  animal  food.  The  por- 
tion of  meat  should  not  be  so  great  as  to  prevent  the  ingestion  of 
other  nutriment.  Nervous  patients  should  not  receive  too  much 
meat;  for  this  class  of  patients,  eggs  should  be  freely  prescribed,  as 
well  as  cheese  and  milk.  The  artificial  protein  preparations  are 
also  worthy  of  consideration  here.     Casein  preparations  are  espe- 


572  GASTROENTEROPTOSIS 

cially  useful  in  cases  where  the  amount  of  food  the  patient  is  able 
to  take  is  small.     (See  Chapter  VIII.) 

Fat,  as  already  intimated,  is  the  most  valuable  article  of  diet 
in  the  food  cure,  owing  to  its  very  high  index  of  combustion.  At 
least  180  Gm.  (6  ounces)  per  day  should  be  tentatively  prescribed. 
Patients  often  consume  with  ease  as  much  as  250  Gm.  (8  ounces) 
of  fat  during  the  twenty-four  hours.  It  is  well  to  have  some 
standard  as  to  the  quantity  of  fat  to  be  consumed  daily  during 
the  course  of  the  food  cure  or  hyperalimentation.  Von  Xoorden 
suggests  the  following  daily  regimen: 

200  Gm.  butter     =     160  Gm.  fat     =     1490  fat  calories. 

1  liter  of  milk    =       33  Gm.  fat     =       307  fat  calories. 

300  Gm.  cream      =       75  Gm.  fat     =       698  fat  calories. 

The  total  amount  of  calories  yielded  by  the  fat  in  this  diet  is 
2495.  Not  every  patient  is  able  to  partake  of  this  quantity  of  fat. 
Cream  in  such  large  amount  is  apt  to  cause  disturbances  which 
destroy  the  appetite.  It  is  possible,  nevertheless,  in  constructing 
a  dietary  with  fat  as  a  fixed  basis,  to  attain  a  high  caloric  value. 
Fat  should  be  prescribed  either  as  liquid  or  in  a  form  easily  reduced 
to  liquid,  such  as  butter,  milk,  yolk  of  egg,  rich  cheese,  and  choco- 
late. The  resourceful  chef  or  housekeeper  will  find  many  ways  in 
which  these  articles  may  be  worked  up  into  a  variety  of  tasty 
dishes.  Butter  may  be  taken  by  itself  or  may  be  made  an  ingre- 
dient of  gravies,  so  that  as  much  as  200  grams  (7  ounces)  per  day 
may  be  easily  ingested.  The  caloric  value  of  milk  may  be  increased 
by  adding  cream.  Coffee,  tea,  or  milk  soups  may  be  administered 
with  milk,  according  to  the  taste.  Kefir  and  yoghurt  are  also 
useful  (see  page  164). 

The  carbohydrates,  owing  to  the  fact  that  they  permit  of  rich 
variety  in  food,  form  important  elements  in  the  food  cure.  They 
also  render  unnecessary  the  prescribing  of  much  protein.  Car- 
bohydrates in  the  hyperalimentation  cure  are  capable  of  being 
absorbed  to  the  amount  of  180  Gm.  (6  ounces)  per  day.  They 
may  be  used  as  vehicles  for  butter,  eggs,  or  milk.  The  carbohy- 
drate carriers  usually  employed  are  wheat  bread,  biscuits,  zwie- 
back, milk  soups,  oatmeal,  cereals,  and  breakfast  foods.  Thick 
soups  are  best  taken  early  in  the  morning  and  during  the  evening 
meal  rather  than  at  noon,  owing  to  their  satiating  qualities.  Oat- 
meal porridge  or  hominy  may  be  eaten  with  cream.  Vegetables 
such  as  potatoes  should  be  given  in  the  form  of  puree  with  large 
quantities  of  fat.  Many  patients  are  particularly  fond  of  choco- 
late, which  may  be  taken  with  or  without  cream.  Sugar  and 
fruit  juices  may  be  prescribed.  Unfermented  grape  juice,  which 
is  very  agreeable  to  the  patient,  may  be  prescribed.  The  malt 
preparations,  such  as  malt  extract,  are  acceptable  to  many  patients; 
they  possess  some  carbohydrate  value. 

Alcohol  is  considered  by  some  authorities  as  possessing  food 


EYDROTHERATEX  TICS  573 

value.     It  is,  however,  of  but  Little  importance  as  an  element  in 

the  food  cure.  Undoubtedly  the  effect  of  alcohol  upon  the  nervous 
system  more  than  offsets  any  virtue  it  may  possess  as  a  food. 

All  dietary  regulations  should  be  made  with  due  regard  to  the 
secretory  and  motor  conditions  of  the  stomach  according  to  the 
directions  laid  down  in  the  chapters  dealing  with  secretory  and 
motor  derangements.  Before  a  food  cure  is  instituted  it  is  neces- 
sary to  know  whether  achylia,  subacidity,  normal  acidity  or  hyper- 
acidity is  present,  and  also  the  condition  of  gastric  motility. 

Under  favorable  conditions  the  food  cure  may  be  carried  on  at 
the  home  of  the  patient.  Better  results,  however,  are  obtained 
when  patients  are  prevailed  upon  to  leave  their  home  surroundings 
and  enter  a  well-managed  hospital  or  a  sanitarium  where  special 
attention  is  given  to  the  dietetic  treatment  of  disease.  Much  is 
achieved  with  this  class  of  patients  by  surrounding  them  with 
salutary  mental  influences.  The  mental  influence  wrhich  the 
physician  may  be  able  to  exert  over  his  patient  has  an  important 
bearing  upon  the  success  of  the  treatment.  An  endeavor  should 
be  made  to  inspire  the  patient  with  hope,  and  to  overcome  as  far 
as  possible  his  prejudices.  Once  the  patient's  wreight  begins  to 
increase,  and  hope  and  confidence  are  established,  there  are  usually 
few  if  any  serious  difficulties  to  overcome.  The  patient  should  be 
educated  to  appreciate  the  nature  of  his  disease;  he  should  under- 
stand that  improvement  will  be  gradual  and  will  depend  largely 
upon  his  habits  of  living  and  his  mental  attitude  for  its  permanency. 

As  the  general  nutrition  of  the  patient  improves,  the  stomach 
and  intestine  will  likewise  become  tolerant  of  a  greater  quantity 
and  variety  of  food.  Patients  with  gastroenteroptosis  compli- 
cated with  neurasthenia  should  be  considered  cured  only  when 
they  may  again  partake  of  a  normal  diet  without  any  distressing 
after-symptoms  and  when  the  work  of  the  intestinal  tract  is  nor- 
mally performed.  To  accomplish  this  result  is  the  purpose  of  the 
food  cure. 

Hydro-therapeutics. — Hydrotherapeutic  measures  may  be  insti- 
tuted and  carried  out  in  conjunction  with  the  food  cure  (see  Chap- 
ter XII) ;  they  should  be  limited,  however,  to  methods  of  a  stimu- 
lating and  invigorating  character.  In  asthenic  conditions  of  the 
heart  muscle,  systematically  performed  respiratory  gymnastics 
are  to  be  carried  out  several  times  a  day.  The  muscles  of  the  body 
may  be  stimulated  by  dry  rubbing  of  the  skin  with  rough  towels. 
The  hydrotherapeutic  procedures  suitable  to  gastroenteroptosis 
complicated  wTith  neurasthenia  consist  in  the  application  of  cold 
water,  half-baths,  Scotch  douches  on  the  abdomen  and  stomach, 
cold  friction,  rubbing  and  slapping,  and  cold  full  packs.  The 
prolongation  and  intensity  of  these  hydrotherapeutic  measures 
must  be  varied  to  suit  the  requirements  of  the  case.  Nervous 
debility  will  at  times  be  greatly  benefited  by  sojourn  in  the  country, 
at  the  seashore,  or  at  some  other  climatic  health  resort. 


574  GASTROENTEROPTOSIS 

Massage  and  Exercise. — Massage  plays  an  important  role  in 
strengthening  the  abdominal  muscles.  For  details  as  to  the 
method  of  procedure,  see  Chapter  X  on  Massage.  In  addition  to 
the  massage  the  patient  should  perform  gymnastic  exercises  to 
invigorate  the  abdominal  wall.  He  may  assume  a  squatting  pos- 
ture, with  the  knees  flexed  until  the  thigh  rests  on  the  calf;  or  he 
may  be  instructed  to  raise  himself  into  the  sitting  posture  when 
lying  flat  upon  the  back.  The  patient  should  be  taught  to  lie 
at  full  length  in  order  to  counteract  atony  of  the  gastro-intestinal 
tract  by  a  better  circulation  of  the  blood.  If  a  bag  of  salt  weighing 
from  one  to  five  pounds  be  placed  on  the  abdomen,  the  efforts 
of  the  patient  to  elevate  the  abdomen  with  this  weight  upon  it  will 
strengthen  the  muscles. 

The  massage  process  in  gastroenteroptosis  must  be  varied  accord- 
ing to  the  anatomic  relations  of  the  parts.  Gastric  massage  may 
immediately  precede  abdominal.  When  these  movements  cannot 
be  conveniently  performed  daily  by  the  physician,  the  patients 
may  practice  on  themselves  by  means  of  a  cannon  ball,  which 
should  not  weigh  more  than  from  three  to  five  pounds.  A  sphere 
of  wood  weighted  with  shot  answers  the  purpose  in  automassage 
very  nicely. 

Electrotherapeutics. — Gastroenteroptosis  is  sometimes  improved 
under  a  course  of  electrotherapeutics.  In  relaxation  of  the  abdom- 
inal muscles  and  intestinal  torpor,  faradization  is  indicated.  Two 
large^plate  electrodes  four  to  six  inches  square  are  applied  to  the 
two  sides  of  the  abdomen,  or,  if  desired,  over  the  epigastric  and 
hypogastric  regions.  The  faradic  current  should  be  turned  on 
slowly  and  its  strength  increased  gradually  so  that  distinct  con- 
traction of  the  abdominal  muscles  becomes  apparent.  The  gal- 
vanic current  is  indicated  in  cases  characterized  by  abdominal 
pains  of  neurotic  origin.  As  much  as  thirty  milliamperes  may  be 
used,  with  one  electrode  over  the  stomach  and  the  other  over  the 
bladder  (see  page  214). 

Mechanical  Treatment  of  Gastroenteroptosis.- — The  mechanical 
therapeutics  consists  principally  in  the  bandaging  of  the  abdomen 
with  a  view  to  supplying  support  to  the  relaxed  abdominal  wall 
and  to  fixing  the  displaced  viscera.  The  treatment  is  merely 
palliative,  but  of  very  great  value.  It  acts  beneficially  by  amelio- 
rating the  symptoms  which  arise  from  tension  or  stretching  of  the 
mesenteries. 

The  mechanical  support  consists  of  abdominal  bandages  or 
abdominal  corsets.  Apparatus  for  this  purpose  is  available  in 
great  variety,  but  everything  has  its  peculiar  defects,  such  as 
uncomfortable  perineal  straps  or  badly  fitting  pads,  which  occa- 
sion patients  no  small  degree  of  annoyance.  It  is  a  very  difficult 
matter  to  find  well-fitting  "ready-made"  abdominal  bandages  or 
corsets.     Among  the  best  known  and  most  suitable  appliances 


MECHANIC  A  L  THE  A  TMENT 


575 


for  the  treatment  of  gastroenteroptosis  are  the  abdominal  bandage 
of  Glenard  and  the  ordinary  silk-rubber  abdominal  bandage  used 
for  a  pendulous  abdomen.  The  latter  possesses  great  adaptability 
and  is  light  in  weight. 

In  order  to  ascertain  whether  a  bandage  is  indicated  in  a  given 
case,  the  so-called  "belt  sign"  of  Glenard  should  be  employed. 
The  physician,  standing  behind  the  patient,  passes  his  arms  on 
either  side  and  places  both  hands  on  the  lower  abdominal  wall. 
With  the  hands  in  this  position  the  abdominal  mass  just  above  the 
pubes  can  be  easily  raised.  The  physician  should  then  suddenly 
remove  his  hands,  permitting  the  abdominal  mass  to  fall;  if  then 
the  patient's  distressing  symptoms,  relieved  by  the  temporary 
support,  return,  the  indication  is  positive  for  the  use  of  an  abdomi- 
nal bandage  or  support.  Glenard  calls  this  phenomenon  "  epreuve 
de  la  sangle"  (Fig.  95).     Should  the  patient  experience  no  relief 


Fig.  95. — Glenard's  "belt  sign"  (epreuve  de  la  sangle). 

when  the  abdomen  is  lifted,  and  feel  if  anything  better  when  it  is 
permitted  to  assume  its  old  position,  the  bandage  will  not  give 
good  results. 

The  Aaron  bandage,1  as  presented  before  the  American  Medical 
Association  at  Philadelphia,  June,  1897,  has  been  used  by  me  with 
success  in  selected  cases  (Figs.  96  and  97).  It  has  in  no  way 
been  modified  from  the  form  introduced  to  the  profession,  and 
has  proved  eminently  satisfactory.  It  is  supplied  with  a  truss 
which  is  fitted  to  the  bandage  encircling  the  body  below  the  crests 
of  the  ilium  and  above  the  trochanter  (Plate  XXIV) .     This  band- 

1  The  bandage  devised  by  the  author  is  manufactured  by  G.  J.  De  Garmo  Co., 
33  West  42d  Street,  New  York. 


576 


G  AST  ROE  N  TEROP  TOSIS 


age  exerts  a  pressure  upon  the  hypogastrium  from  below  upward, 
raising  the  intestine,  which  in  turn  acts  as  a  cushion  for  the  stomach. 
In  this  way  the  tension  upon  the  abdominal  organs  is  relieved. 
The  bandage  should  be  adjusted  properly  in  order  to  prevent 
slipping  up  at  the  back,  or  no  benefit  will  be  derived  from  its  use 
(Plate  XXV,  Fig.  2).  When  properly  applied  it  affords  abdomi- 
nal support  and  at  the  same  time  leaves  the  ribs  and  diaphragm 
free  from  all  compression  and  the  respiratory  movements  free. 
There  is  no  pressure  over  the  solar  plexus.  The  wearing  of  this 
bandage  tends  to  develop  in  patients  a  deep,  broad,  prominent 
lower  chest  and  epigastrium,  which  is  the  condition  found  in  well- 
developed  normal  individuals  (Plate  XXV,  Fig.  1). 


Fig.  96. — Author's  abdominal  bandage. 


This  bandage  has  been  found  valuable  in  the  treatment  of  abdom- 
inal pain  due  to  a  loose  sacro-iliac  joint.  This  pain  sometimes 
extends  through  to  the  front  of  the  joint,  where  it  is  most  apt 
to  be  mistaken  for  an  affection  of  some  pelvic  organ.  The  exist- 
ence of  this  condition  is,  as  a  rule,  indicated  by  the  fact  that  the 
affected  leg  is  shortened,  and  that  pain  results  when  the  leg  is 
rotated,  forced  strongly,  or  pulled  outward.  Most  of  these  patients 
are  relieved  by  the  application  of  the  bandage. 


PLATE    XXIV 


Abdominal  Bandage  in   Position. 


PLATE    XXV 

FIG.   I  FIG.  2 


Abdominal  Bandage 
Properly  Adjusted. 


Abdominal  Bandage  Im- 
properly Adjusted. 


.1/  /<,'(  'IIAXICAL  THE  A  TMENT 


:.77 


Measurements  for  the  author's  bandage  must  be  exact  and  should 
be  taken  with  all  the  clothing  removed  (Fig.  98).  J,  carry  tape 
around  hips  at  pubis,  -  -  inches;  K,  carry  tape  around  hips 


jvG.  97. — Author's  abdominal  bandage,  showing  construction  in  detail. 

at  anterior  superior  spine  of  ilium, inches;  L,  carry  tape 

around  abdomen  six  inches  above  pubis, inches;  M,  width  of 

pelvis  between  the  anterior  superior  spines  of  the  ilium,  with  the 

abdomen  well  compressed, inches. 

37 


578 


GASTROENTEROPTOSIS 


An  appliance  very  much  in  vogue  is  an  adhesive-plaster  bandage, 
by  Rose,  of  New  York.  It  consists  of  zinc  oxide  moleskin  adhe- 
sive plaster  one  yard  long  and  eight  inches  wide.  From  this  a 
pattern  is  cut  as  shown  in  Fig.  99.  I  am  in  the  habit  of  placing 
the  patient  in  the  Trendelenburg  position  in  order  to  apply  this 
plaster  bandage.  All  hairy  portions  of  the  body  covered  by  the 
bandage  should  be  shaved  to  facilitate  removal.  The  plaster  should 
not  include  the  crest  of  the  ilium,  but  should  run  closely  along  and 
above  it.  The  epigastric  region  remains  uncovered  (Fig.  100). 
Most  patients  find  this  bandage  fairly  comfortable.  Patients  are 
able  to  bathe  regularly  while  wearing  it.  They  often  learn  to 
apply  it  properly  themselves.  Unfortunately,  it  is  impossible  to 
keep  it  in  place  longer  than  three  or  four  weeks,  owing  to  the  fact 
that  the  plaster  loses  its  adhesiveness. 


Fig. 


-Diagram,  showing  lines  of  measurements  for  bandage. 


The  removal  of  adhesive  plaster  from  the  skin  of  a  patient  is 
accompanied  by  considerable  pain  and  discomfort.  Oil  of  winter- 
green  completely  destroys  the  adhesive  elements  in  a  very  short 
time.  It  is  not  necessary  to  use  more  than  a  small  amount  of  the 
oil,  which  is  applied  directly  to  the  plaster  and  easily  spreads  itself 
throughout  the  adhesive  material.  When  extensive  areas  of  plaster 
are  to  be  removed  the  application  of  an  ointment  of  adeps  lanse 
hydrosus,  with  10  per  cent,  of  oil  of  wintergreen  incorporated,  is 
even  more  useful  than  the  oil  alone.  A  little  gasoline  in  a  medicine 
dropper  allowed  to  drop  under  the  plaster  so  relaxes  the  adhesive- 
ness that  the  plaster  can  be  easily  removed.  Better  still,  soak  the 
plaster  with  gasoline  applied  with  a  piece  of  gauze  or  cotton.  The 
plaster  can  be  thus  easily  loosened  and  removed. 

Corsets.- — The  corsets  most  in  use  are  those  devised  by  Barden- 
heuer,  Landau,  Gallant,  and  Fitz.  Gallant  advocates  the  semi- 
opisthotonos  posture  (Fig.  101)  as  the  proper  one  for  the  patient 


MECHANICAL  TREA  TMENT 


579 


Fig.  99. — Pattern  for  adhesive  belt.     (Rose.) 


Fig.  100. — Adhesive-plaster  belt  adjusted.     (Rose.) 


580 


GASTROENTEROPTOSIS 


to  assume  in  putting  on  his  corset.  A  good  corset  should  be  high 
and  snug-fitting  in  the  back,  low  and  loose  over  the  epigastrium, 
long  and  close-fitting  at  the  pubes,  short  behind  and  well  molded 
to  the  sacrum  from  which  it  takes  support. 

The  corset  I  prescribe  is  an  ordinary  long-hip,  straight-front 
corset,  and  may  be  purchased  at  any  up-to-date  corset  shop. 
Its  main  feature  is  the  fact  that  it  laces  in  front.  When  properly 
adjusted  it  forms  a  valuable  therapeutic  factor  in  the  treatment 
of  gastroenteroptosis.  This  is  especially  true  when  the  abdomen 
is  prominent,  protruding  anteriorly  to  the  spines  of  the  ilium. 
The  corset  is  not  so  beneficial  when  the  abdomen  is  flat;  in  such 
cases  the  author  applies  his  abdominal  bandage. 


Fig.  101. — Position  for  adjusting  corset.     (Gallant.) 


Method  of  Adjusting  Corset. — The  corset  should  be  opened  the  full 
length  of  the  strings  before  hooking.  After  the  corset  is  hooked 
in  front  it  should  be  pulled  down  as  far  as  possible  by  grasping 
the  lower  edge  with  one  hand,  the  undergarment  being  pulled  up 
with  the  other.  When  the  lower  edge  of  the  corset  is  half-way 
over  the  symphysis,  the  garters  should  be  fastened  all  around, 
and  the  buckles  so  adjusted  as  to  tighten  the  garters.  The  corset 
should  be  laced  from  below  up  to  the  eighth  eyelet  like  a  shoe, 
thus  gradually  raising  the  displaced  organs.  Now  start  at  the  top 
and  lace  down  to  the  waist  line,  leaving  the  corset  loose  enough  to 
relieve  pressure  in  the  epigastrium.  The  laces  should  be  tied  at 
the  waist  line,  when  the  corset  will  be  found  to  be  in  proper  posi- 
tion. This  corset  presses  over  the  hypogastrium,  so  that  when  it 
is  laced  the  lower  abdomen  has  become  less  prominent  (Plate 
XXVI). 


PLATE    XXVI 


Corset  Adjusted  Correctly. 
Side  View. 


MEDICINAL  TREATMENT  581 

Pregnancy  has  frequently  had  the  effect  of  so  raising  the  abdomi- 
nal organs  as  to  bring  about  recovery  in  cases  of  gastroenteroptosis. 
Women  with  ptosis  who  become  pregnant  have  an  increased  intra- 
abdominal pressure,  which  will  vary  directly  as  the  uterus  increases 
in  volume.  Pregnancy  produces  a  marked  improvement  in  the 
digestive  functions  in  these  cases,  and  there  is  no  reason  why  this 
improvement  may  not  be  made  permanent  through  proper  treat- 
ment. It  becomes  markedly  apparent  during  the  later  months  of 
pregnancy.  Normal  pregnancy,  then,  does  not  exert  any  bad 
influence  upon  gastroenteroptosis.  If  after  delivery  the  viscera 
are  sustained  with  a  properly  fitted  bandage  for  some  time,  a  con- 
traction of  the  abdominal  walls  takes  place  and  in  due  time  the 
organs  will  continue  in  their  proper  position. 

Medicinal  Treatment. — Most  patients  suffering  from  gastroenterop- 
tosis require  iron  in  some  form.  They  cannot  take  it  internally, 
owing  to  its  irritating  effect  upon  the  gastric  mucous  membrane. 
This  difficulty  may  be  overcome  by  hypodermic  medication.  Of 
all  the  iron  preparations,  ferric  citrate  has  been  found  best  for 
hypodermic  use;  as  a  reconstructive  hematinic  it  is  probably  the 
best  form  of  the  metal.  Combined  with  arsenic,  iron  acts  as  an 
alterative,  and  the  compound  may  be  used  in  all  cases  of  cachexia 
and  in  all  anemias.  Iron,  arsenic  and  strychnin  in  the  form  of 
glycerophosphates  are  indicated  in  disturbances  of  a  nervous  nature, 
particularly  in  those  neuromuscular  cases  where  there  is  a  marked 
deficiency  of  phosphates.  The  cacodylate  of  iron  is  particularly 
valuable  in  combating  the  graver  forms  of  anemia  which  are  found 
sometimes  associated  with  gastroenteroptosis.  Owing  to  the  fact 
that  this  preparation  is  well  borne  by  the  kidneys,  it  can  be  pre- 
scribed in  all  cases  of  anemia  and  kidney  involvement. 

Of  all  methods  of  administering  drugs,  the  hypodermic  is  giving 
the  best  results.  The  colloidal  metals  have  a  pronounced  biologic 
influence  on  the  body.  The  electro-colloids  of  iron,  silver,  gold, 
copper  and  mercury  can  be  given  intravenously.  The  cacodylate 
of  iron  and  the  cacodylate  of  sodium  have  proved  of  great  value 
when  given  intravenously.  The  Italians  have  done  much  to 
develop  this  mode  of  administering  pharmacopceial  preparations. 
These  preparations  are  put  up  in  the  form  of  aseptic  solutions  in 
hermetically  sealed  glass  ampoules.1  Their  method  of  adminis- 
tration is  as  follows:  The  stem  of  the  ampoule  in  which  the  dose 
is  contained  is  broken  off,  and  the  dose  drawn  up  into  the  syringe 
under  aseptic  conditions.  The  injections  are  made  deep  into  the 
gluteal  region;  they  should  be  given  intramuscularly.  Iron  caco- 
dylate may  be  safely  given  intravenously.  The  following  combina- 
tions can  be  used: 

1  By  Molteni  &  Company,  of  Florence,  Italy;  imported  by  L.  A.  Seltzer,  of 
Detroit,  Mich. 


582  GASTROENTEROPTOSIS 

Grams. 

Iron  cacodylate 0 1 03 

Iron  citrate  (green) 0 1 05 

Sodium  arsenate 0 1 001 

Iron  citrate  (green) 0 1 05 

Iron  citrate  (green) 0 1 05 

Strychnin  sulphate 0|001 


Iron  citrate  (green) 0 

Sodium  arsenate 0 

Strychnin  sulphate 0 

Iron  citrate  (green) 0 

Sodium  glycerophosphate 0 

Sodium  arsenate 0 


05 

001 

0005 

05 
05 

001 


Iron  citrate  (green) 0 1 05 

Sodium  glycerophosphate 0  05 

Strychnin  sulphate 0  (001 


Iron  citrate 0 

Sodium  glycerophosphate  ■  . 0 

Sodium  methylarsenate 0 

Strychnin  sulphate 0 

Iron  citrate 0 

Sodium  glycerophosphate 0 

Sodium  methylarsenate 0 

Strychnin  sulphate 0 

Iron  citrate 0 

Sodium  glycerophosphate 0 

Sodium  methylarsenate 0 

Sodium  formate 0 

Strychnin  sulphate 0 


05 
20 
10 
001 

10 
50 
10 
001 

05 
20 
10 
15 

001 


Liquid  petrolatum  (purified  mineral  oil)  is  indicated  when  we 
desire  to  lubricate  the  whole  gastro-intestinal  tract  to  facilitate 
the  passage  of  its  contents.  The  feces  are  softened  and  under  the 
microscope  are  found  to  contain  minute  globules  of  the  oil.  Too 
heavy  an  oil  should  not  be  used,  for  this  fails  to  permeate  the  fecal 
material,  a  desideratum  as  important  as  the  lubrication  of  the 
intestinal  wall.  The  oil  is  not  absorbed  from  the  alimentary  tract, 
and  even  in  large  doses  has  no  poisonous  effect.  It  is  useful  not 
only  as  a  lubricant,  but  also  as  a  means  of  healing  superficial  lesions 
of  the  mucous  membrane.  It  may  be  given  for  any  irritation  of 
the  mucous  membrane  of  the  gastro-intestinal  tract  with  absolute 
safety.  The  oil  inhibits  bacterial  growth.  In  tablespoonful  doses 
three  times  daily  it  acts  as  a  mild  laxative  (see  page  664) . 

Improvement  in  the  appetite  sometimes  follows  the  adminis- 
tration of  a  stomachic.  Where  atony  is  present  the  medicinal 
agents  appropriate  for  that  condition  may  be  given  (see  Chapter 
XXIV). 

Mineral  waters,  when  they  seem  to  be  indicated,  should  be 
prescribed  tentatively  according  to  the  principles  given  for  the 


SURGICAL  TREATMENT  583 

treatment  of  atony.    In  cases  where  there  is  much  distress,  mineral 
waters  are  contra-indicated. 

Surgical  Treatment. — Operative  measures  have  been  employed 
for  the  relief  of  severe  symptoms  incident  to  gastroenteroptosis 
of  marked  degree.  One  of  these  is  the  fixation  of  the  stomach 
to  the  parietal  peritoneum  by  the  shortening  of  the  ligaments 
(gastropexy).  The  operation  for  nephropexy  also  has  been  em- 
ployed. The  lesser  omentum  of  the  stomach  has  been  attached 
to  the  anterior  abdominal  wall.  The  fasciae  of  the  gastric  muscles 
have  been  resected  and  sutured.  The  colon,  hepatic  and  splenic 
flexures  have  been  attached  to  the  anterior  abdominal  wall.  A 
hammock  has  been  made  of  the  great  omentum  for  the  suspension 
of  the  stomach.  Surgical  plication  of  the  gastrohepatic  and  gas- 
trophrenic ligaments  with  three  rows  of  sutures  has  been  done. 
The  recti  muscles  have  been  so  united  with  kangaroo-tendon  sutures 
as  to  cause  overlapping.  Many  other  original  surgical  measures 
have  been  employed.  The  results  obtained  by  these  operations 
have  not,  however,  been  encouraging;  and  since  surgical  interven- 
tion has  proved  ineffectual  in  the  treatment  of  gastroenteroptosis, 
gastroenterologists  have  practically  ceased  to  advise  it.  Better 
reports  on  the  surgical  relief  of  chronic  intestinal  stasis  by  the 
removal  of  pericolic  membranes,  bands,  kinks,  etc.,  have  been 
made.     (See  Chapter  XXXIX.) 


CHAPTER  XXXI. 

DISEASES  OF  THE  LIVER. 

Hepatitis;  Abscess;  Yellow  Atrophy;  Febrilis  Icterus; 
Hyperemia;  Cirrhosis;  Atrophy;  Syphilis;  Tuberculosis; 
Neoplasms;  Parasites;  Fatty  Liver;  Neuralgia. 

ACUTE  AFFECTIONS  OF  THE  LIVER. 

Acute  Inflammation  of  the  Liver. — The  question  whether  there 
is  a  pure  form  of  primary  hepatic  inflammation  is  not  easily 
decided,  because  in  every  case  of  inflamed  liver  there  is  a  possi- 
bility of  its  having  been  caused  by  some  other  hepatic  affection 
accompanied  by  inflammatory  manifestations.  Cases  of  apparent 
primary  hepatitis  occur  mostly  in  the  tropics,  notably  following 
malaria  and  dysentery,  but  also  after  exposure,  dietary  errors,  or 
abuse  of  alcohol.  According  to  the  general  description,  it  mani- 
fests itself  without  premonitory  signs,  with  chill,  high  fever,  and 
pain,  and  disappears  when  the  patients  conform  to  a  correct  mode 
of  living.  There  may,  however,  be  relapses.  The  etiology  of 
these  manifestations  is  not  established,  but  intestinal  toxemia  or 
infection  should  be  considered.  Possibly  hyperemia  of  the  liver, 
common  in  the  tropics  as  a  result  of  dietetic  errors  and  excesses, 
supplies  a  groundwork  for  acute  inflammations. 

In  northern  countries  hepatic  inflammation  is  characterized  by 
a  more  or  less  pronounced  swelling  of  the  liver,  pain,  tension  and 
pressure  in  that  organ,  sometimes  by  a  slight  rise  in  temperature, 
and  sometimes  icterus;  but  all  these  manifestations  recede  in  a 
short  time.  As  already  stated,  it  is  difficult  to  decide  whether  the 
inflammatory  state  of  the  liver  which  they  express  is  or  is  not 
secondary  to  some  other  hepatic  disorder. 

Treatment. — The  treatment  consists  of  rest  in  bed,  abstinence 
from  alcohol  and  all  injurious  articles  of  diet,  and  the  use  of  light, 
non-irritating  foods.  In  the  first  stage  of  the  illness  mild  laxatives 
are,  in  order,  such  as  calomel  0.03  Gm.  (f  grain)  one  or  two  doses, 
then  rhubarb,  cascara,  senna,  etc.  After  a  cure  has  been  effected 
alcohol  should  be  avoided  for  a  long  time,  and  the  diet  should 
continue  bland  until  all  danger  of  relapse  is  past.  Should  there 
be  frequent  relapses,  a  change  of  climate  is  desirable. 

Abscess  of  the  Liver. — Suppurative  hepatitis  is  either  primary  or 
secondary.  Primary  abscess  of  the  liver  is  usually  of  traumatic 
origin,  occurring  after  contusions  or  direct  injuries  from  stabs  or 


ACUTE  AFFECTIONS  OF  THE  LIVER  ."i.s:> 

shots.  Secondary  abscess  is  due  to  invasion  of  the  liver  by  bacteria 
and  parasites  from  other  parts  of  the  body.  Septic  processes  are 
of  first  importance,  the  infectious  material  spreading  to  the  liver 
in  the  form  of  emboli,  especially  in  cases  of  ulcerous  endocarditis. 
Other  sources  of  infection  are  ulceration  and  gangrene  of  the  lungs, 
bronchiectasis,  putrid  bronchitis,  all  kinds  of  ulcers  and  abscesses 
occurring  from  birth  to  old  age,  especially  appendicitis,  salpingitis, 
suppurative  inflammation  of  the  gall  bladder  and  biliary  ducts, 
and  finally,  in  the  tropics,  dysentery,  in  which  the  Endamebie  coli 
migrate  into  the  liver.  Although  the  possibilities  of  the  occur- 
rence of  liver  abscess  are  almost  unlimited,  it  develops  compara- 
tively rarely  in  the  temperate  zones,  both  sexes  being  affected  in 
about  the  same  proportion.  In  the  tropics,  however,  males  are 
oftener  attacked,  evidently  as  a  result  of  the  abuse  of  alcohol  and 
immoderate  eating  and  drinking. 

According  to  the  size  and  number  of  the  abscesses,  the  liver  is 
more  or  less  enlarged,  either  the  whole  organ  or  only  one  of  the 
lobes  being  involved.  When  the  abscesses  contain  large  quantities 
of  pus  they  often  push  out  the  overlying  skin,  forming  palpable 
protuberances,  while  superficial  abscesses  which  are  not  subjected 
to  high  pus  pressure  form  fluctuating  sacs.  The  tropical  abscess 
has  a  predilection  for  the  right  lobe  and  is  usually  solitary.  The 
pus  is  either  of  a  creamy  consistency,  or  more  serous,  biliary  or 
bloody,  of  chocolate  color,  often  of  putrid  odor,  and  may  contain 
numerous  tissue  threads;  at  times  it  contains  small  gallstones. 
The  abscesses  are  mostly  encapsulated  in  connective  tissue,  which 
is  apt  to  become  hard  and  thick,  lined  with  a  villous  stratum  of 
changed  hepatic  tissue,  pus  and  bacteria.  The  neighboring  hepatic 
cells  show  fatty  degeneration,  occasionally  gangrene  and  necrosis, 
with  thrombosis  and  thrombophlebitis  of  the  hepatic  veins.  The 
suppurative  inflammation  frequently  spreads  beyond  the  liver, 
causing  adhesions  and  encapsulated  abscesses  which  may  be  sub- 
phrenic or  located  in  the  pleura  or  the  lung.  Perforation  into  the 
abdominal  cavity,  stomach,  intestine  or  the  larger  vessels  occurs 
less  often.  Nevertheless,  perforation  into  the  renal  pelvis,  esopha- 
gus and  pericardium  have  been  reported.  Even  descending 
abscesses  along  the  ligamentum  teres,  with  perforation  of  the 
abscess  at  the  umbilicus,  may  occur. 

Symptoms. — Most  secondary  abscesses  show  but  indifferent 
symptoms,  or  none  at  all,  and  are  usually  completely  concealed  by 
the  underlying  affection.  They  are  often  not  discovered  until 
the  cause  (appendicitis)  has  run  its  course.  A  symptom  of  abscess 
is  high  temperature  of  a  remittent  or  intermittent  character, 
complicated  by  chills.  Considerable  night-sweats  are  not  infre- 
quent. On  the  other  hand,  fever  may  be  entirely  absent  in  many 
cases,  especially  in  the  later  stages.  Changes  in  the  shape  of  the 
liver  may  clinically  be  observed  by   inspection  and  palpation, 


586  DISEASES  OF  THE  LIVER 

according  to  the  size  and  number  of  the  abscesses.  When  the  latter 
are  fresh,  there  is  pain,  both  spontaneously  and  upon  pressure;  the 
pains  may  radiate  toward  the  back,  right  shoulder  and  right  upper 
arm.  The  skin  generally  has  a  sallow  color.  There  is  considerable 
emaciation.  The  spleen  is  often  enlarged  and  the  digestion  dis- 
turbed. Urobilin  and  urobilinogen  have  been  found  in  the  urine. 
Involvement  of  the  lungs  and  pleura  or  reflex  irritation  of  the 
phrenic  nerve  may  cause  considerable  paroxysms  of  coughing. 
High  position  of  the  diaphragm  may  give  rise  to  dyspnea.  The 
diagnosis  is  made,  if  possible,  by  test  puncture.  The  differential 
diagnosis  between  empyema  of  the  pleura,  subphrenic  abscess,  and 
liver  abscess,  can  usually  be  correctly  made,  especially  with  the 
aid  of  the  Roentgen  ray,  if  all  the  existing  possibilities  are  duly 
taken  into  consideration. 

With  the  patient  in  a  semiprone  position,  traction  on  the  umbili- 
cus in  the  direction  of  the  pubis  will  often  elicit  pain  in  the  region 
of  the  liver.  This  referred  pain  is  present  in  cases  of  cholecystitis, 
hepatic  abscess,  and  other  diseased  conditions  of  the  liver. 

Spontaneous  resolution,  or  spontaneous  perforation  of  the  pus 
outward,  followed  by  a  cure,  is  always  exceptional.  The  disease 
runs  a  fatal  course  unless  the  pus  can  be  evacuated. 

Treatment. — The  only  rational  therapy  is  surgical.  When  the 
presence  of  an  abscess  has  been  established  by  puncture,  a  broad 
incision  is  made  at  the  point  of  puncture.  If,  in  the  absence  of 
pus  after  a  test  puncture,  there  are  other  symptoms  pointing  to 
the  probability  of  an  abscess,  the  latter  may  sometimes  be  found 
by  palpation  and  opened  after  laparotomy  or  costal  resection.  The 
abscess  cavity  should  be  irrigated  with  saline  solution. 

If  the  abscess  cannot  be  located  by  puncture,  internal  treat- 
ment is  in  order.  The  latter  can,  of  course,  be  symptomatic  only. 
Pain  and  swelling  of  the  liver  are  relieved  by  cold  compresses,  ice 
or  leeches  applied  to  the  hepatic  region.  The  intestinal  function  is 
incited  by  mild  laxatives  and  bitters.  The  diet  should  be  light, 
pulpy,  fluid  and  non-irritating,  but  withal  nutritious  and  con- 
centrated, in  order  to  provide  for  maintenance  of  the  strength 
necessary  for  the  operation  which  may  have  to  follow  later.  Dysen- 
tery, if  present,  should  be  carefully  treated  (see  Chapter  XLIII). 
Tropical  patients  had  best  be  sent  home. 

Emetin  hydrochlorid  has  proved  curative  in  amebic  abscess  of 
the  liver,  injected  after  withdrawal  by  trocar  of  the  pus,  and  later 
subcutaneously  (see  page  723). 

Acute  Yellow  Atrophy  of  the  liver. — Acute  parenchymatous 
hepatitis,  or  icterus  gravis,  is  relatively  rare  and  occurs  after  infec- 
tious diseases,  typhoid,  recurrent  fever,  erysipelas,  diphtheria,  in  the 
early  stages  of  syphilis,  and  particularly  during  pregnancy  and  the 
puerperium.  Accordingly,  the  female  sex  is  oftener  attacked  than 
the  male.    The  early  symptoms  are  hardly  noted — slight  dyspepsia 


ACUTE  AFFECTIONS  OF  THE  LIVER  587 

and  a  Little  jaundice;  but  after  these  have  persisted  for  one  or  two 
weeks  the  ease  suddenly  assumes  a  serious  form,  with  vomiting, 
eructations,  nausea,  and  pain  in  the  back  and  in  the  hepatic  region. 
The  patient  becomes  listless  and  a  prey  to  hallucinations  and 
delirium,  with  increasing  icterus  of  the  gravest  form,  death  result- 
ing in  a  few  days.  During  this  time  the  liver  decreases  in  volume, 
and  the  hepatic  dulness  may  sometimes  (though  not  always) 
completely  disappear,  while  the  spleen  becomes  enlarged.  There 
is  considerable  rise  in  temperature  toward  the  end.  Sometimes 
there  are  cutaneous  hemorrhages  and  epistaxis.  The  quantity  of 
urine  is  considerably  decreased,  and,  aside  from  biliary  pigment, 
albumin  and  casts,  the  urine  contains  the  aminoacids  leucin  and 
tyrosin,  which  are  characteristic  of  the  disease;  also  sarcolactic 
acid,  oxyhydrocyanic  acid,  and  peptoid  bodies.  Leucin  and  tyrosin 
have  also  been  found  in  the  gall  bladder.  At  autopsy  the  liver 
is  found  to  be  shrunk  to  one-half  of  its  size  or  less,  the  left  lobe 
being  more  involved  than  the  right;  the  whole  organ  shows  a  dirty 
reddish-yellow  discoloration;  its  surface  is  often  spotted,  brownish- 
red  and  gray  areas  alternating  with  yellow  and  greenish-yellow. 
The  cut  surface  is  also  discolored,  the  yellow  parts  being  more 
prominent  than  the  red.  Under  the  microscope  extensive  degenera- 
tion of  the  hepatic  cells  is  seen,  together  with  a  small-celled  inter- 
stitial proliferation.  Leucin  and  tyrosin  may  be  found  in  the 
interior  of  the  hepatic  and  portal  veins. 

This  is  a  primary  acute  affection  of  the  liver,  possibly  due  to 
a  kind  of  toxemia  from  the  intestine  through  the  portal  vein. 
Specific  microorganisms  have  not  been  found.  The  affection  ter- 
minates fatally,  the  number  of  reported  apparently  spontaneous 
cures  being  exceedingly  fewr. 

Treatment. — The  treatment  can  only  be  symptomatic,  consist- 
ing of  ice  and  morphin  for  vomiting  and  pain,  ice-bags  and  cold 
compresses  applied  to  the  liver  and  head.  The  vitality  of  the 
patient  should  be  kept  up  by  light  nutrition,  so  far  as  possible. 

Febrilis  Icterus. — This  acute  febrile  jaundice  is  called  "Weil's 
disease"  because  it  was  first  described  by  Weil  in  1866.  It  usu- 
ally occurs  in  young  men,  commencing  with  chills,  high  fever, 
anorexia,  thirst,  and  vomiting.  The  temperature  falls  between 
the  third  and  the  fifth  day,  then  rises,  and  again  lytically  declines 
to  the  middle  of  the  second  week.  Jaundice  usually  occurs  during 
the  first  days  or  when  the  fever  declines;  sometimes,  however,  the 
feces  are  not  discolored  and  the  urine  is  free  from  bilirubin,  sug- 
gesting hemolytic  icterus.  The  fever  is  accompanied  by  painful 
swelling  of  the  liver,  enlargement  of  the  spleen,  acute  nephritis, 
muscular  pain,  especially  in  the  calves,  dyspeptic  symptoms,  and 
manifestations  of  excitation.  Exanthemata,  herpes,  hemorrhages 
into  the  mucous  membranes  and  retinal  hemorrhages  have  also 
been  observed.     The  affection  usually  takes  a  favorable  course. 


588  DISEASES  OF  THE  LIVER 

The  few  cases  which  have  come  to  autopsy  have  not  shown  any 
characteristic  hepatic  changes. 

A  specific  cause  of  the  disease  is  now  supposed  to  be  a  plicate 
spirochete  (Uhlenbuth  and  Fromme)  which  does  not  coil  in  regular 
spirals.  This  parasite  shows  swellings  and  nodules  and  is  called 
Spirocheta  nodosa.  Japanese  investigators  have  inoculated  guinea- 
pigs  with  the  blood  of  patients  suffering  from  infectious  hemor- 
rhagic jaundice  resembling  Weil's  disease  and  thus  transmitted  the 
disease  with  all  its  characteristic  symptoms.  They  then  dis- 
covered, in  the  blood  of  the  animals  as  well  as  in  that  of  the  human 
patients,  a  microorganism  which  they  designated  Spirocheta  icter- 
hemorrhagicB.  This  organism  has  been  demonstrated  to  be  the  cause 
of  Weil's  disease.  It  is  now  believed  that  the  strains  of  these  spiro- 
chetes are  identical.  The  spirochetes  are  found  constantly  in  the 
blood.  Spirochetal  jaundice  has  shown  a  mortality  of  10  per 
cent,  on  both  the  eastern  and  western  coasts.  The  organisms  are 
extremely  motile  and  can  penetrate  the  unbroken  skin.  Noguchi 
has  found  them  in  wild  rats  in  New  York  City.  The  disease  is  sup- 
posed to  be  spread  by  rats.  In  many  cases,  apparently,  the  icterus 
has  followed  ingestion  of  decomposed  food,  especially  meat;  but 
toxemia  also  may  be  responsible. 

Treatment. — The  treatment  consists  in  the  injection  of  serum 
taken  from  a  convalescent  horse.  Good  results  have  followed 
this  therapy.  The  fever  is  treated  with  antipyretics  (quinin,  pyra- 
midon) ;  the  dyspeptic  manifestations  are  relieved  by  mild  laxatives, 
the  manifestations  of  collapse  by  analeptics,  and  the  nervous 
excitement  by  narcotics.  Among  the  latter  may  be  recommended 
subcutaneous  injections  of  morphin-scopolamin  (scopolamin  hydro- 
bromid  0.0005,  morphin  0.01);  also  2  or  3  grams  (gr.  xxx-xlv)  of 
chloral  hydrate  per  rectum.  Tepid  baths,  gradually  cooled  down, 
are  advisable.  In  some  cases  the  intravenous  injection  of  arsphena- 
mine  or  neoarsphenamine  is  of  great  benefit  (see  page  534). 

CHRONIC  AFFECTIONS  OF  THE  LIVER. 

Active  Hyperemia. — This  hyperemia  is  due  to  an  excessive  supply 
of  arterial  blood,  caused  by  persistent  dietary  errors  (too  abundant 
and  too  frequent  meals);  alcoholism;  overindulgence  in  coffee, 
spices  and  meat;  infectious  diseases  (malarial,  typhoid  or  yellow 
fever);  climatic  injuries  (tropical  climate);  menstrual  irregulari- 
ties; trauma  in  the  hepatic  region;  or  biliary  colic.  All  these 
may  cause  acute  and  chronic  hyperemia.  The  liver  is  enlarged, 
a  condition  which  is  particularly  characteristic  when  the  enlarge- 
ment is  subject  to  frequent  changes  or  to  complete  temporary  dis- 
appearance. At  the  same  time  the  organ  is  sensitive  to  pressure, 
even  pressure  of  the  clothing.  The  pain  is  occasioned  by  pulling 
and  pressure  on  the  hepatic  capsule,  which  contains  numerous 


CHRONIC  AFFECTIONS  OF  THE  LIVER  589 

sensory  nerves.  There  is  a  sensation  of  heaviness  in  the  gastric 
and  hepatic  regions;  the  patients  feel  a  subjective  disturbance  of 
digestion,  though  the  digestive  organs  are  intact;  they  feel  very 
nervous  and  irritable,  which  is  accounted  for  by  the  persistent 
recurrence  of  the  causative  noxious  factors  and  consequent  hyper- 
cniic  condition. 

Diagnosis. — The  diagnosis  of  active  hyperemia  is  not  always  easy 
and  can  only  be  verified  by  continued  observation.  The  hyperemia 
may  be  the  first  sign  of  a  beginning  grave  hepatic  affection.  On 
percussion  the  lower  edge  of  the  liver  is  extremely  painful. 

Treatment. — In  the  first  place  the  causative  factors  are  to  be 
eliminated — which  means,  primarily,  restriction  in  the  quantity 
and  quality  of  food.  Only  small  portions  of  meat,  preferably  very 
tender  and  soft,  should  be  allowed.  A  lactovegetable  diet,  con- 
sisting of  milk,  farinaceous  food,  buttermilk,  yoghurt,  green  vege- 
tables, legumes,  fruit,  and  tea,  is  likewise  in  order;  while  heavy, 
very  fat  meats,  smoked  and  pickled  meats,  alcohol  and  strong 
condiments  are  excluded.  The  intestinal  function  is  to  be  gently 
excited  by  the  vegetable  bitters  or  alkaline  mineral  waters,  or 
mild  vegetable  laxatives.  In  chronic  conditions  a  stay  at  West 
Baden,  Saratoga,  Kissingen.  Carlsbad,  Betrich  or  Vichy  is  to  be 
considered,  always  provided  the  patient  is  willing  to  adapt  his 
entire  way  of  living  to  the  requirements  of  the  cure.  Local  pains 
are  relieved  by  cold  compresses,  ice-bags,  dry  cupping,  or  deferent 
plasters. 

Passive  Hyperemia. — Congestion  of  the  liver  is  met  with  in 
all  affections  which  impede  the  flow  of  the  venous  blood  toward 
the  heart.  This,  therefore,  includes  all  valvular  irregularities  and 
other  disorders  of  the  heart  and  large  vessels  which  lead  to  cardiac 
weakness.  Again,  all  affections  of  the  lungs  or  other  pectoral 
organs,  especially  also  kyphosis  and  scoliosis,  lead  to  engorgement 
of  the  liver.  In  these  conditions  the  liver  is  hypertrophied,  dark 
blue  to  red  in  color,  and  of  hard  consistency.  The  lobular  centers 
in  the  transverse  section  are  more  vividly  red  than  the  periphery, 
which  accounts  for  the  characteristic  appearance  of  the  cut  surface 
designated  as  nutmeg  liver.  In  persistent  engorgement,  parts  of 
the  liver  undergo  atrophic  obliteration,  causing  proliferation  of 
the  intralobular  connective  tissue,  which  means  shrinking  of  certain 
parts  of  the  liver,  while  other  parts  will  correspondingly  protrude. 
This  causes  the  liver  to  become  harder  and  smaller.  The  surface 
is  more  granulated,  showing  a  certain  similarity  to  cirrhosis  and 
constituting  the  atrophic  nutmeg  liver. 

Symptoms. — The  hepatic  congestion  is  accompanied  by  a  feeling 
of  pressure  and  pain  in  the  affected  region.  Usually,  however, 
these  symptoms  are  less  pronounced  than  those  which  are  caused 
by  the  underlying  affection.  The  diagnosis  is  established  by 
inspection,  palpation,  and  percussion. 


590  DISEASES  OF  THE  LIVER 

Treatment. — The  treatment  is  directed  to  the  underlying  affec- 
tion. So  far  as  the  liver  is  concerned,  light  and  not  abundant 
nutrition,  attention  to  the  fecal  evacuation,  and  avoidance  of  the 
injurious  influences  mentioned  in  the  treatment  of  active  hyper- 
emia, are  of  importance. 

Atrophic  Cirrhosis.- — Chronic  interstitial  hepatitis,  or  atrophic 
cirrhosis,  is  a  disease  of  the  liver  with  marked  increase  of  the  con- 
nective tissue,  which  afterward  contracts,  producing  atrophy  and 
degeneration  and  giving  the  organ  a  granular,  yellow  appearance 
(granular  atrophy)  due  to  the  coloring  of  the  acini  by  the  biliary 
pigments. 

Etiology.- — Atrophic  cirrhosis,  known  as  Laennec's  disease,  may 
be  due  to  any  one  of  ,a  number  of  causes.  Although  there  is  no 
doubt  that  the  role  of  alcohol  as  a  causative  factor  has  been  over- 
estimated, the  fact  remains  that  a  large  proportion  of  cases  are 
to  be  attributed  to  the  abuse  of  alcohol.  Many  authors  assume  an 
endogenous  development  of  hepatic  cirrhosis.  The  endogenous 
theory,  if  accepted,  accounts  for  pancreatic  cirrhosis  and  similar 
injuries  to  other  organs  (as  the  spleen),  as  well  as  for  hepatic 
cirrhosis.  It  is  also  assumed  that  toxins  from  chronic  gastric  and 
intestinal  catarrh  are  conducted  to  the  liver  through  the  portal 
vein,  there  causing  the  characteristic  changes  of  the  periportal  tissue. 
Alcohol  thus  comes  in  for  a  share  of  the  blame  on  the  ground  that 
its  use,  or  abuse,  favors  the  development  of  gastric  and  intestinal 
catarrh.  It  has  been  experimentally  demonstrated,  though  not 
in  human  pathology,  that  lead,  organic  acids  and  other  substances 
may  produce  cirrhosis.  Nor  is  there  any  doubt  that  infectious 
diseases  predispose  to  cirrhosis,  as  has  been  observed  in  syphilis, 
tuberculosis,  and  malaria.  As  a  matter  of  fact  any  disorder  capable 
of  setting  up  acute  hepatitis  can  lead  to  cirrhosis,  because  hepatitis 
may  cause  cirrhosis — for  instance,  after  scarlet  fever.  Japanese 
authors  have  reported  that  hepatic  cirrhosis  has  occurred  after 
infection  with  Schistosoma  japonica,  an  intestinal  parasite,  prob- 
ably by  direct  mechanical  irritation  of  the  hepatic  tissue.  So  far 
as  the  great  majority  of  cases  of  atrophic  cirrhosis  of  the  liver 
are  concerned,  it  must  be  assumed  in  a  general  way  that  they  are 
caused  by  a  toxin  introduced  by  the  portal  vein.  It  has  been 
reported  that  atrophic  cirrhosis  has  occurred  in  gout  and  diabetes. 
Individuals  between  the  ages  of  forty  and  sixty  are  the  most  fre- 
quent victims,  while  in  the  very  old  and  the  very  young  the  affec- 
tion has  been  found  but  rarely. 

"Pathology. — The  pathologic  changes  of  the  liver  in  cirrhosis  are 
characteristic.  As  a  rule  the  shape  of  the  organ  is  unaltered, 
but  it  is  frequently  so  shrunken  in  size  as  to  have  lost  half  its 
weight.  Its  surface  is  covered  with  small  excrescences,  from  pin- 
head  to  pea  size,  a  smooth  surface  being  the  exception.  The 
hepatic  capsule  is  often  cloudy  and  thickened  in  places  by  callosi- 


CHRONIC  AFFECTIONS  OF  THE  LIVER  591 

ties.  The  liver  substance  is  very  hard,  so  hard  that  it  can  only 
with  difficulty  be  cut.  In  most  cases  the  left  lobe  is  more  involved 
than  the  right.  The  cut  surface  exposes  the  proliferated  connec- 
tive tissue  in  the  shape  of  a  whitish,  reddish  or  gray  net,  the  meshes 
of  which  contain  what  has  been  preserved  of  the  hepatic  paren- 
chyma. Microscopically,  these  coarse  anatomic  changes  are  seen 
to  have  been  caused  by  a  rather  advanced  degree  of  proliferation 
of  the  interlobular  connective  tissue.  The  latter,  encircling  the 
lobes,  sends  out  solitary  strands  between  the  various  acini.  The 
development  of  the  connective  tissue,  however,  is  always  inter- 
lobular. The  liver  cells,  which  exhibit  cloudy  swelling  and  fatty 
degeneration,  gradually  perish  in  the  zone  of  contact  with  the 
connective  tissue.  There  are  inflammatory  changes  of  the  blood- 
vessels in  the  form  of  periphlebitis  or  phlebitis  with  partial  oblitera- 
tion of  the  veins.  Parts  of  the  connective  tissue,  too,  show  small- 
celled  infiltration.  At  the  same  time  neoplasms  of  the  hepatic 
tissue  and  particularly  of  the  biliary  capillaries  are  occasionally 
found. 

Symptoms.- — The  early  symptoms  of  hepatic  cirrhosis  are  dys- 
peptic, with  eructations,  constipation  or  diarrhea,  and  a  sensation 
of  weakness.  As  these  symptoms  increase,  the  face  becomes  sallow 
and  the  sclera?  painful  and  discolored.  These  symptoms  may 
persist  for  years,  in  varying  intensity,  before  the  unmistakably 
characteristic  manifestations  of  cirrhosis  appear.  Gradually, 
changes  in  the  liver  itself  become  apparent — enlargement  fol- 
lowed by  shrinking,  or  conspicuous  hardness.  Unless  the  abdom- 
inal walls  are  very  thick,  unevenness  of  the  hepatic  surface  can  be 
discovered  by  palpation.  In  most  cases  there  is  little  or  no  sen- 
sitiveness to  pressure.  It  is  only  with  the  onset  of  inflammation 
of  the  hepatic  capsule  that  any  marked  degree  of  pain  is  experi- 
enced. In  a  considerable  number,  but  by  no  means  all  cases, 
there  is  gradual  enlargement  of  the  spleen;  it  is  probable  that  this 
splenic  hypertrophy  is  due  to  the  same  toxins  that  affect  the  liver; 
in  most  cases  there  are  no  characteristic  changes  in  the  structure  of 
the  spleen.  Jaundice  occurs  in  some  cases,  but  not  often.  The 
discoloration  of  the  skin,  referred  to  above,  is,  however,  character- 
istic. The  feces  are  colored  accordingly.  Defecation  is  often 
irregular,  diarrhea  alternating  with  constipation  in  the  presence 
of  pronounced  meteorism.  One  of  the  characteristic  symptoms 
is  abdominal  ascites,  which  develops  pari  passu  with  the  hindrance 
to  the  portal  circulation  caused  by  connective-tissue  proliferation 
and  shrinking  of  the  hepatic  lobes.  But  portal  stasis  is  surely 
not  always  the  cause  of  ascites;  it  is  probable  that  chronic  inflam- 
matory changes  in  the  hepatic  capsule  and  the  peritoneum,  together 
with  contraction  of  the  mesentery,  favor  its  occurrence.  In  the 
initial  stage  of  ascites  the  swelling  abdomen,  pushing  upward  on 


592  DISEASES  OF  THE  LIVER 

the  well-filled  stomach,  causes  elevation  of  the  diaphragm,  dis- 
placement of  the  heart,  and  compression  of  the  lungs.  The  ascitic 
fluid  is  usually  limpid  and  yellowish,  and  its  specific  gravity  goes 
up  to  1015;  the  albuminous  content  amounts  to  0.5  to  2  per  cent. 
As  the  damming  of  the  hepatic  circulation  increases,  the  portal 
blood  endeavors  to  find  other  means  of  reaching  the  vena  cava, 
and  the  possibility  of  its  doing  so  through  the  gastric  and  esophageal 
veins  is  to  be  considered.  Owing  to  the  plethora  of  these  veins 
and  the  portal  stasis,  varices  are  easily  formed  which  may  burst 
in  the  esophagus,  giving  rise  to  hemorrhages  of  varying  extent. 
Similarly,  overdistention  of  the  hemorrhoidal  veins  may  cause 
hemorrhoids  and  hemorrhages.  Should,  then,  the  mesenteric  and 
epigastric  veins  anastomose,  the  veins,  notably  of  the  anterior 
abdominal  wall,  protrude  in  the  shape  of  bluish  cords,  especially 
in  the  umbilical  region,  forming  the  so-called  caput  medusas.  Again, 
new  venous  tracts  in  the  ligamentum  teres  may  run  to  the  veins 
of  the  abdominal  walls.  In  a  small  number  of  cases  of  atrophic 
cirrhosis  there  is  no  ascites.  Fever  is  rare.  The  quantity  of 
voided  urine  is  small  in  proportion  to  the  collection  of  ascites. 
Unless  icterus  is  present,  there  is  no  demonstrable  biliary  pigment, 
but  there  are  urobilin  and  urobilinogen.  In  most  cases  patients 
become  anemic  to  a  rather  marked  degree.  There  is  no  difficulty 
in  making  the  diagnosis  in  fully  developed  cases,  but  in  the  initial 
stages  the  anamnesis  is  the  principal  reliance  of  the  diagnostician. 
The  diminished  content  of  fibrinogen  in  the  blood  is  an  aid  in  the 
diagnosis  (see  page  384). 

On  account  of  the  destruction  of  its  cells  the  liver  does  not 
function  normally.  This  can  often  be  ascertained  by  the  several 
functional  tests: 

Tests  for  Lipase. — Normally  the  blood  contains  a  definite  per- 
centage of  lipase  or  lipolytic  ferment.  That  one  of  the  functions 
of  the  liver  is  to  control  within  normal  limits  the  circulation  of 
lipase  in  the  blood  is  inferred  from  the  fact  that  in  certain  diseases 
of  the  liver  the  percentage  is  increased.  It  was  found  by  Whipple, 
in  collaboration  with  Mason  and  Peightol,  that  after  acute  hepatic 
injury  from  chloroform  the  percentage  of  lipase  in  the  blood  serum 
or  plasma  was  always  increased.  For  estimating  the  amount 
of  lipase  in  the  blood,  1  Cc.  of  blood  serum  is  placed  in  each  of 
four  tubes,  and  4  Cc.  of  distilled  water  added  to  each.  Two  of 
these  filled  tubes  are  used  as  controls.  To  each  of  the  others  0.26 
Cc.  of  ethyl  butyrate  (butyric  ether)  is  added.  All  four  are  shaken, 
corked,  and  incubated  at  38°  C.  for  eighteen  to  twenty-four  hours, 
then  cooled  in  ice-water,  3  drops  of  azolitmin  added  to  each,  and 
titrated  in  pairs  with  decinormal  acid  and  alkali  solutions — the 
controls  with  the  former,  the  others  with  the  latter.  The  con- 
trols show  the  natural  alkalinity  of  the  blood;  and  to  this  figure  is 


CHRONIC  AFFECTIONS  OF  THE  LIVER  593 

added  the  free  butyric  acid  figure  found  in  the  lipase  test  tubes, 
to  determine  the  total  butyric  acid  formed.1 

Levulose  Test. — The  levulose  test  for  hepatic  insufficiency  depends 
upon  the  finding  of  unassimilated  sugar  in  the  urine.  The  patient 
is  given  GO  Gm.  (2  ounces)  of  levulose  on  an  empty  stomach.  If 
a  healthy  individual  ingests  this  quantity,  a  positive  reaction  is 
almost  never  obtained.  The  test  is  a  functional  one.  The  physio- 
logic duty  of  the  liver  is  to  store  up  glycogen.  The  liver  metabo- 
lism is  so  deranged  in  certain  chronic  diseases,  such  as  cirrhosis, 
atrophic  processes,  and,  in  general,  destruction  of  the  liver  paren- 
chyma, that  levulose  is  found  in  the  urine.  For  testing  in  levulo- 
suria,  a  simple  Nylander  reaction  is  sufficient.  To  10  parts  of  the 
urine  under  test  add  1  part  of  the  Nylander  solution,  consisting  of 
2  parts  bismuth  subnitrate  and  4  parts  sodium  and  potassium  tar- 
trate dissolved  in  100  parts  of  a  10-per-cent.  solution  of  sodium 
hydroxid.  The  presence  of  glucose  is  indicated  by  black  coloration 
or  precipitate. 

Phthalein  Test. — It  has  been  found  that  phenoltetrachlorphthalein 
is  eliminated  entirely  by  way  of  the  bile.  This  drug  has  been  utilized 
in  testing  the  function  of  the  liver,  just  as  the  function  of  the 
kidneys  is  tested  with  sulphonephthalein.  A  freshly  prepared, 
boiled,  isotonic  solution  of  phenoltetrachlorphthalein  in  distilled 
water  is  administered  intravenously,  and  after  free  purgation  the 
stools  are  collected  during  forty-eight  hours  and  tested  for  the  drug. 
About  30  to  40  per  cent,  of  the  phthalein  is  normally  recovered. 
This  test  for  liver  function  is  a  difficult  one,  and  recent  reports 
indicate  that  the  information  thus  adduced  is  not  as  valuable  as 
was  at  first  supposed. 

Urobilin. — In  the  majority  of  cases  sufficient  functioning  cells 
persist  to  enable  the  liver  to  maintain  its  metabolic  processes  in 
approximate  equilibrium.  Urobilin  is  normally  formed  from  the 
biliary  coloring  material  in  the  intestine.  This  material  is  carried 
to  the  liver  and  is  there  transformed  into  biliary  pigment.  Should 
the  parenchyma  of  the  liver  be  unable  to  properly  perform  this 
function,  urobilin  or  urobilinogen  is  found  in  the  urine.  Urobilin- 
uria  is  the  invariable  accompaniment  of  disease  of  the  liver.  It  is 
probably  the  first  appreciable  symptom  of  cirrhosis  of  the  liver 
and  the  first  symptom  of  beginning  obstruction  to  the  outflow  of 
bile,  and  it  is  the  last  to  disappear  when  the  bile  stasis  has  been 
corrected.  ^Yhen  obstruction  is  so  complete  that  no  bile  enters 
the  intestine,  there  can  be  no  urobilinuria;  hence  the  absence  of 
urobilinuria  in  diseases  of  the  liver  testifies  to  complete  obstruction 
of  the  bile  passage. 

Prognosis.- — Generally  speaking,  the  prognosis  is  unfavorable. 
Even  though  the  affection  may  be  protracted  for  years  and  remain 

1  Lowenhart,  American  Journal  of  Physiology,  1902,  vi,  331. 
38 


594  DISEASES  OF  THE  LIVER 

at  a  standstill  for  a  number  of  years,  it  is  fatal  in  the  majority  of 
cases.  The  number  of  cases  in  which  a  final  cure,  or  at  least  a 
resolution  of  the  manifestations,  has  been  claimed,  is  very  few. 

Treatment. — All  injurious  indulgences  are  to  be  avoided.  Alcohol 
is  rigorously  prohibited.  Attempts  should  be  made  to  raise  the 
power  of  resistance  by  rest,  good  nursing  and  diet,  fresh  air  and 
skin  culture,  in  order  to  offer  the  liver  a  certain  degree  of  partici- 
pation in  the  general  recuperation.  The  diet  should  be  light  and 
bland,  but  plentiful,  corresponding  to  the  protective  treatment  of 
chronic  gastric  or  intestinal  catarrh.  Meat  should  be  sparingly 
partaken  of,  and  salt  avoided,  to  promote  diuresis  as  in  cases  of 
nephritis. 

Recently  Einhorn  has  recommended  duodenal  alimentation 
(eee  page  500)  in  hepatic  cirrhosis,  assuming  that  it  facilitates 
hepatic  function  by  stimulating  the  portal  circulation. 

Frequent  baths  (with  or  without  medicaments),  ablutions,  and 
friction  with  water  or  spirituous  solutions  are  indicated.  Increased 
diuresis  will  induce  absorption  and  elimination  of  the  ascitic  fluid. 
Elimination  should  be  promoted  at  an  early  stage  by  the  adminis- 
tration of  mild  laxatives  (senna,  rhubarb,  cascara  sagrada,  phenol- 
phthalein).  Diuretics,,  such  as  theobromin  sodiosalicylate,  theo- 
bromin,  theophyllin,  euphyllin,  to  be  administered  by  mouth  or  as 
suppositories  several  times  daily,  come  in  for  particular  considera- 
tion. It  is  advisable  to  prescribe  theophyllin  and  euphyllin  period- 
ically because  their  effect  extends  over  a  few  days  only.  After  a 
lapse  of  one  or  two  weeks  they  may  again  be  used  for  a  few  days. 
Caffein  sodiosalicylate  has  an  excellent  effect.  So  long  as  the 
kidneys  are  healthy,  concentrated  solutions  of  urea  (20,  aq.  ad 
200,  one  tablespoonful  every  hour)  are  advantageous  in  some 
cases.  Calomel  in  large  doses  is  sometimes  used  as  a  last  resort  in 
order  to  avoid  abdominal  puncture,  0.2  Gm.  (3  grains)  being  given 
four  times  daily.  It  may  also  be  combined  with  urea  according  to 
the  following: 

Gm.  or  Cc. 
]$ — Hydrargyri  chloridi  mitis  ....       0  [  1  gr.  iss 

Urese  purse 1 1 0  gr.  xv 

Misce  et  ft.  pulv.  no.  xxv. 

Sig. — One  powder  three  times  daily. 

The  administration  of  calomel,  however,  demands  great  care, 
owing  to  the  grave  stomatitis  it  may  occasion,  and  also  because  its 
excretion  appears  to  be  hindered  by  the  hepatic  affection. 

Keratin  seems  to  be  an  antisclerotic  remedy  of  some  value. 
The  patient  is  given  1  Gm.  (15  grains)  of  keratin  three  times  a 
day,  and  the  dose  is  gradually  increased  up  to  2  Gm.  (30  grains). 
It  must  be  given  for  several  months.  Should  there  be  a  gastro- 
intestinal irritation,  with  diarrhea,  bismuth  salicylate  is  to  be  given 
in  doses  of  0.5  Gm.  (7%  grains)  every  three  or  four  hours.  Fibrol- 
ysin  has  been  used  in  some  cases  (see  page  484). 


CHRONIC  AFFECTIONS  OF  THE  LIVER  595 

Should  syphilis  enter  into  the  question  of  etiology,  iodids  may 
be  administered  tentatively  in  large  doses  in  the  shape  of  sodium 
iodid,  potassium  iodid,  iodipin,  or  iodalhin.  The  need  of  caution 
in  the  administration  of  calomel,  referred  to  above,  applies  to 
other  mercurials  as  well. 

Eichhorst  warmly  recommends  bitartrate  of  potassium  to  relieve 
ascites.  When  used  for  several  weeks,  this  compound  is  said  to  be 
strikingly  effective,  probably  on  account  of  its  diuretic  properties. 

Gm.  or  Cc. 

1$ — Decoctiradici  althxae 10—18 10  5iiss-iyss 

Potassii  bitartratis 15  0  5iv 

Syrupi 20]0  5v 

Misce. 

Sig. — One  tablespoonful  every  two  hours,  well  shaken. 

Should  it  be  impossible  to  control  the  ascites  by  any  means 
whatever,  paracentesis  will  have  to  be  resorted  to.  The  consensus 
of  opinion  favors  an  early  puncture,  before  very  large  quantities  of 
fluid  have  accumulated,  even  when  no  more  than  1§  to  2  liters 
is  present.  Indeed,  objections  are  no  longer  raised  to  very  fre- 
quent abdominal  punctures,  because  frequent  and  early  relief  of 
the  abdomen  from  the  ascitic  pressure  has  a  very  favorable  effect 
upon  the  local  and  general  circulation  and  incites  the  kidneys  to 
greater  activity.  The  question  whether  all  or  only  part  of  the  fluid 
should  be  evacuated  is  not  of- very  great  importance,  because  there 
is  certain  to  be  reaccumulation  after  the  first  puncture,  so  that  a 
fresh  puncture  becomes  imperative  in  any  case.  This  procedure 
is  very  simple.  An  ordinary  pleural  or  abdominal  trocar  is  used. 
With  the  patient  in  the  sitting  posture,  the  puncture  is  made 
immediately  above  the  symphysis  in  the  median  line,  the  bladder 
having  been  previously  evacuated.  When  the  patient  is  in  the 
lateral  decubitus  the  puncture  is  made  in  the  elongated  median 
axillary  line.  Should  intestinal  loops  present  in  the  opening,  they 
may  be  pushed  aside  by  a  sterile  soft-rubber  catheter  or  a  mandrin 
which  fits  into  the  trocar,  evacuation  being  hastened  by  varying 
the  position  of  the  patient  or  by  manual  pressure  upon  the  various 
abdominal  regions.  The  opening  is  closed  with  adhesive  plaster 
after  the  trocar  has  been  removed.  In  the  event  of  any  fluid  oozing 
out,  the  opening  may  be  sutured,  or  a  needle  is  thrust  into  the 
elevated  skin  fold  and  a  thread  wound  around  it  to  compress  the 
puncture. 

Surgical  Treatment. — Atrophic  cirrhosis  of  the  liver  has  also 
pressed  surgery  into  its  service  for  the  relief  of  portal  stasis.  Talma 
and  Drummond  suture  plethoric  abdominal  organs  (omentum, 
spleen,  gall  bladder)  to  the  anterior  abdominal  wall,  embedding 
the  same  in  a  subperitoneal  pouch,  in  the  hope  that  the  veins  of 
these  organs  will  communicate  with  the  veins  of  the  abdominal 
walls  and  form  a  collateral  circulation.     This  procedure  is  particu- 


596  DISEASES  OF  THE  LIVER 

larly  suitable  for  those  forms  of  cirrhosis  in  which  icterus  is  lacking 
and  those  in  which  the  manifestations  of  engorgement  occupy  the 
foreground.  These  authors  report  a  few  cases  in  which  a  cure  has 
been  effected  in  this  way. 

Ech's  fistula  consists  of  an  artificial  communication  between 
the  portal  vein  and  the  vena  cava.  Since  we  have  been  able  to 
better  the  technic  of  uniting  bloodvessels,  this  surgical  operation 
has  been  more  successful  than  formerly. 

Hypertrophic  Cirrhosis.— Hypertrophic  cirrhosis  of  the  liver,  or 
Hanot's  disease,  is  essentially  different  from  the  form  just  described. 
The  connective-tissue  proliferation  is  located  extra-  and  intra- 
lobularly  and  shows  no  tendency  to  reduce  the  size  of  the  liver. 
The  material  feature  of  the  affection  consists  in  the  fact  that  the 
liver  cells  themselves  become  enlarged,  that  their  protoplasm  and 
nuclei  increase  in  volume,  and  also  that  the  number  of  the  nuclei 
increases.  Numerous  new  biliary  capillaries  are  formed  at  the  same 
time.  These  changes  of  the  hepatic  tissue  cause  considerable 
enlargement  of  the  entire  organ  which  persists  during  the  continu- 
ance of  the  affection.  The  liver  may  attain  to  a  weight  of  2\  to  4 
kilos.  It  is  hard  and  smooth  to  the  touch.  The  capsule  on  exami- 
nation is  often  found  cloudy  and  callous,  due  to  perihepatic  changes. 
As  a  consequence,  there  are  often  adhesions  to  the  neighboring 
organs.  Cross-section  of  the  parenchyma  shows  yellowish  green, 
and  the  glistening  strands  of  connective  tissue  can  be  seen  to  traverse 
the  parenchyma. 

Etiology. — The  etiology  of  this  affection  is  still  entirely  unex- 
plained. Alcohol  does  not  appear  to  play  any  important  'role. 
Some  authors  consider  infectious  cholangitis  the  cause.  The 
patients  are  usually  men  between  twenty  and  thirty  years  of  age, 
although  the  disease  has  been  observed  in  children. 

Symptoms. — The  early  symptoms  are  vaguely  dyspeptic,  fol- 
lowed by  jaundice  and  hepatic  discomfort,  a  sensation  of  ten- 
sion and  heaviness  in  the  abdomen,  lassitude,  and  irregular  con- 
sistency of  the  stools.  Gradually,  permanent  jaundice  develops. 
The  liver  becomes  enlarged  and  indurated,  a  splenic  tumor  being 
formed  at  the  same  time.  Hypertrophic  cirrhosis  of  the  liver  is 
characterized  by  the  absence  of  all  signs  of  portal  stasis,  especially 
of  ascites.  The  quantity  of  urine  is  abundant.  The  urine  con- 
tains biliary  pigment  and  urobilinogen.  The  reserve  force  and 
sustenance  of  the  patient  are  rapidly  impaired,  and  the  skin  becomes 
dry.  The  jaundice  causes  considerable  itching.  The  stool  is  but 
seldom  acholic.  At  times  there  is  fever.  Toward  the  end,  hemor- 
rhages from  the  nose,  gums  and  skin  are  common.  Patients  may, 
however,  continue  to  live  tolerably  well  for  years  until  the  increas- 
ing debility  renders  them  unfit  for  work;  and  increasing  cardiac 
weakness  and  general  tabescence  denote  the  near  approach  of  death. 


CHRONIC  AFFECTIONS  OF  THE  LIVER  597 

Diagnosis.  It  is  always  difficult  to  make  a  safe  diagnosis.  In 
the  initial  stage  the  differential  diagnosis  between  atrophic  and 
hypertrophic  cirrhosis  is  especially  difficult.  A  safe  diagnosis, 
also,  as  against  carcinoma,  can  usually  not  be  made  until  a  later 
stage  has  developed. 

Prognosis.-  The  prognosis  is  unfavorable. 

Treatment. — The  general  treatment  coincides  with  that  of  atrophic 
cirrhosis.  Einhorn's  plan  of  duodenal  alimentation  (p.  500)  might 
also  be  taken  into  consideration,  this  author  having  often  observed 
prompt  reduction  in  the  size  of  the  enlarged  liver  as  a  result. 
Iodin  preparations  may  be  used  tentatively.  A  number  of  authors 
recommend  calomel,  0.01  to  0.02  Gm.  (£  to  |  grain)  three  to  five 
times  daily,  in  the  beginning  of  the  treatment,  to  be  given  for  a 
week,  followed  by  an  interval  of  several  weeks.  The  possibility  of 
resulting  stomatitis  should  never  be  lost  sight  of. 

Hypertrophic  Cirrhosis  of  the  Liver  in  Bronze  Diabetes. — This 
affection  is  characterized  by  the  well-known  triad  of  abnormalities, 
diabetes  mellitus,  pigment  deposits  in  the  skin  and  internal  organs, 
and  hypertrophic  cirrhosis  of  the  liver.  It  is  of  particularly  frequent 
occurrence  in  England  and  France,  and  but  rarely  observed  else- 
where. The  conspicuous  symptom  is  the  brown  or  dark  gray 
discoloration  of  the  skin,  which,  however,  does  not,  as  in  Addison's 
disease,  extend  to  the  mucous  membrane.  At  the  same  time 
the  symptoms  of  moderate  or  grave  diabetes  are  present,  as  well 
as  the  symptoms  of  hepatic  cirrhosis.  Anatomically  we  find  the 
hypertrophic  form  of  hepatic  cirrhosis,  plus  abundant  deposits  of 
brown  pigment  in  the  liver  cells  and  connective  tissue.  This  is 
iron  pigment,  and  the  liver  is  consequently  very  ferruginous.  This 
pigment  is  also  found  in  other  organs,  such  as  the  pancreas  and 
spleen.  It  is  found  in  the  cutis  rather  than  in  the  epidermis. 
Jaundice  is  absent  in  this  form  of  cirrhosis. 

Treatment.— Here,  again,  the  treatment  is  simply  symptomatic, 
chiefly  intended  to  relieve  the  diabetes  and  cirrhosis. 

Biliary  Cirrhosis. — Biliary  cirrhosis  is  a  form  of  Laennec's  cirrhosis 
which  has  developed  from  mechanical  occlusion  of  the  biliary  excre- 
tory ducts,  especially  the  ductus  choledochus,  or  is  due  to  calculi, 
tumor  adhesions,  or  scars.  However,  every  persistent  occlusion  ot 
the  choledochus  in  man  does  not  necessarily  lead  to  cirrhosis. 

At  first  the  liver  is  enlarged,  firm  and  smooth.  Transverse 
section  shows  an  intensely  greenish-yellow  color,  due  to  the  widening 
of  the  biliary  passages  and  the  diffusion  of  the  biliary  pigment. 
The  hepatic  cells  degenerate  under  the  influence  of  the  engorged 
bile.  At  the  same  time  there  is  considerable  tissue  proliferation, 
partly  in  the  neighborhood  of  the  biliary  ducts,  partly  between 
the  lobes,  which  gradually  increase  in  size,  finally  assuming  an 
anatomic  picture  identical  with  that  of  Laennec's  cirrhosis. 

This  form  of  cirrhosis  is  attended  at  the  very  beginning  by  con- 


598  DISEASES  OF  THE  LIVER 

siderable  jaundice.  Unless  the  biliary  stasis  is  relieved,  a  splenic 
enlargement  will  develop,  together  with  ascites,  leading  to  a  fatal 
termination  in  a  comparatively  short  time  as  a  result  of  cholemia 
and  circulatory  disturbances.  The  diagnosis  of  cirrhosis  when  the 
ductus  choledochus  is  occluded  cannot,  as  a  rule,  be  made  until 
after  death. 

Treatment. — The  treatment  is  symptomatic  only  and  coincides 
with  that  of  atrophic  cirrhosis,  unless  surgical  intervention  be 
invoked. 

Cirrhosis  Occurring  in  the  Course  of  Affections  of  the  Circulatory 
Organs.— Cirrhosis  may  develop  from  passive  hyperemia  of  the 
liver  in  arteriosclerosis,  cardiac  disease,  and  portal  thrombosis. 

Pericarditic  pseudohepatic  cirrhosis,  first  described  by  Friedel 
Pick,  does  not  correspond  to  the  nature  of  cirrhosis  proper.  Chronic 
pericarditis,  with  adhesions  between  the  pericardial  layers,  is 
very  often  accompanied  by  chronic  hepatitis  with  hyperplasia  of 
the  liver.  The  capsule  of  the  liver  is  often  exceedingly  thickened 
and  may  have  a  perfectly  white  appearance;  hence  Curschmann's 
"sugar-coated  liver"  ("Zuckergussleber"). 

ATROPHY  OF  THE  LIVER. 

Brown  Atrophy. — General  disturbances  of  nutrition,  senile  mar- 
asmus, inanition  and  cachexia  affect  the  liver  as  well  as  other 
organs;  it  becomes  smaller,  darker,  browner,  tough  and  coarse  to 
the  touch,  and  has  a  wrinkled  capsule.  The  liver  cells,  too,  are 
atrophied,  contracted,  and  filled  with  dark  pigment.  Hence  the 
term  "brown  atrophy."  This  form  of  atrophy  may  also  be  caused 
by  an  isolated  disturbance  of  hepatic  nutrition — for  instance,  by 
involvement  or  compression  of  the  portal  vein. 

Red  Atrophy. — Persistent  venous  congestion  of  the  liver  may 
also  lead  to  atrophy  of  the  parenchyma,  which  is  called  "red" 
from  the  fact  that  the  liver  assumes  a  bluish-red  color,  setting  off 
the  whitish  network  of  the  acini  sharply,  especially  as  seen  on  cross- 
section  (cyanotic  nutmeg  liver).  The  affection  is  caused  by  pres- 
sure of  the  plethoric  central  veins  upon  the  surrounding  cells, 
which  gradually  atrophy.  The  clinical  manifestations  correspond 
to  those  of  passive  hyperemia  of  the  liver;  occasionally  light  icterus 
accompanies  the  other  symptoms. 

Treatment  has  to  be  restricted  to  the  underlying  cardiac  and 
pulmonary  affections. 

Partial  Atrophy. — This  form  of  atrophy  is  caused  by  compres- 
sion of  isolated  parts  of  the  liver  by  tumors  or  other  processes, 
intra-  or  extrahepatic.  In  this  way  obliteration  of  the  cells  and 
vessels  may  occur,  together  with  a  circumscribed  inflammation, 
thickening  and  cicatrization. 


SYPHILIS  OF  THE  LIVER  509 

SYPHILIS  OF  THE  LIVER. 

Congenital  Syphilis. — This  form  of  syphilis  is  already  present  in 
the  new-bora  or  develops  during  the  first  months  of  life.  Infants 
with  congenital  syphilis  of  the  liver  are  emaciated,  ill-nourished, 
and  stunted.  The  abdomen  is  usually  distended.  The  liver  is 
enlarged,  smooth  and  indurated.  The  spleen  also  is  apt  to  be 
enlarged.  Other  signs  of  congenital  syphilis  are  frequent,  such 
as  glandular  swellings,  ozena,  pemphigus,  etc.  Pathologically,  the 
syphilitic  liver  of  the  new-born  is  distinguished  by  proliferation 
of  the  interstitial  connective  tissue,  starting  from  the  capsule  and 
spreading  interlobularly  in  the  course  of  the  disease.  In  most 
cases  of  congenital  hepatic  syphilis  there  is  also  perihepatitis  with 
adhesions  to  the  neighboring  organs.  Gummata  are  rather  rare 
and  occur  only  in  the  shape  of  small  nodules.  Owing  to  the  con- 
nective-tissue proliferation,  congestive  manifestations  and  ascites 
may  develop,  as  in  atrophic  cirrhosis,  and  the  liver  may  also  undergo 
atrophy.  In  the  new-born  and  infants,  jaundice  is  likely  to  be 
present.  The  little  patients,  becoming  more  and  more  debilitated 
from  week  to  week,  contract  gastric  and  intestinal  disturbances 
which  lead  to  early  death. 

Acquired  Syphilis. — Acquired  syphilis  produces  characteristic 
changes  in  the  liver.  Here,  again,  there  is  considerable  prolifera- 
tion of  the  interstitial  connective  tissue,  with  hypertrophy  or  atrophy 
of  the  organ.  Gummata  are  not  uncommon — from  the  size  of  a  pea 
to  that  of  an  orange;  they  are  situated  usually  near  the  surface 
of  the  liver,  often  immediately  under  the  capsule.  These  gummata 
are  firm-tissued,  but  readily  break  down  from  interior  necrosis, 
gradually  undergoing  cicatrization  and  forming  coarse  scar  tissue, 
the  shrinking  of  which  may  grotesquely  alter  the  shape  of  the  liver 
and  its  capsule.  This  process  is  usually  accompanied  by  pro- 
nounced perihepatitis  and  adhesions  of  the  liver  to  neighboring 
organs.  Small,  diffuse,  inflammatory  foci  are  of  rarer  occurrence. 
The  gummata  may  also  cause  fatty  degeneration  and  atrophy  of 
the  hepatic  parenchyma. 

Symptoms. — In  adults  syphilis  of  the  liver  may  persist  for  a 
long  time  without  giving  rise  to  any  marked  symptoms.  In  the 
course  of  time  pains  will  develop  in  the  hepatic  region;  these  are 
usually  due  to  enlargement  of  the  liver  or  friction  upon  contact 
with  perihepatic  processes.  A  striking  and  characteristic  feature 
of  many  cases  consists  of  intermittent  fever  and  chills.  In  the 
absence  of  other  etiologic  factors,  fever  and  hepatic  changes  are 
always  suggestive  of  syphilis.  The  hepatic  pains  are  sometimes 
very  severe,  occur  in  paroxysms,  and  are  particularly  aggressive 
during  the  night.  The  spleen,  in  some  cases,  is  enlarged.  Jaundice 
is  not  a  constant  symptom.  Ascites  often  appears  at  an  early 
stage. 


600  DISEASES  OF  THE  LIVER 

Diagnosis. — The  diagnosis  of  syphilis  of  the  liver  is  usually  very 
simple  in  the  new-born.  In  older  children  and  in  adults,  where 
acquired  syphilis  may  have  to  be  considered,  the  anamnesis  is  of 
importance,  likewise  the  TYassermann  or  Noguchi  reaction  and  the 
result  of  antisyphilitic  treatment.  The  prognosis  is  not  unfavor- 
able, as  a  rule.  Under  appropriate  treatment  a  cure  is  often 
effected,  or  at  least  resolution  and  arrest  of  further  progress.  On 
the  other  hand,  some  cases  are  very  resistant  to  treatment. 

Treatment. — The  treatment  is  antisyphilitic.  Iodin,  mercury  and 
arsphenamine  suggest  themselves  (see  page  534).  Extensive  gum- 
matous formations  have  been  subjected  to  surgical  treatment,  and 
gummatous  nodules  have  been  successfully  enucleated.  "V\ nen,  in 
dubious  cases,  antisyphilitic  treatment  is  not  successful,  an  explor- 
atory laparotomy  is  indicated  for  both  diagnostic  and  therapeutic 
purposes. 

TUBERCULOSIS  OF  THE  LIVER. 

Primary  tuberculosis  of  the  liver  is  hardly  likely  to  occur.  On 
the  other  hand,  the  liver  often  becomes  involved  in  a  general 
tubercular  infection.  In  pulmonary  tuberculosis  the  liver  may  be 
affected  by  congestion  and  by  fatty  degeneration  of  the  parenchyma. 
Tubercular  processes  in  the  liver  usually  take  the  form  of  miliary 
areas  in  the  interlobular  connective  tissue.  In  the  further  course 
they  lead  to  interstitial  hepatitis  and  cellular  infiltration.  The 
bacilli  migrate  into  the  liver  by  way  of  the  arteries,  but  also  through 
the  portal  vein,  especially  in  intestinal  tuberculosis.  Large  soli- 
tary tubercles,  or  accumulations  of  the  same,  are  relatively  rare. 
When  superficial  tubercles  do  occur,  they  may  lead  to  perihepatitis 
and  adhesions.  It  has  already  been  stated  that  cirrhosis  may 
occur  as  a  result  of  hepatic  tuberculosis;  but  clinically  it  occupies  a 
less  prominent  position  than  the  other  features  of  the  pathologic 
picture.     The  treatment  is  directed  to  the  underlying  affection. 

NEOPLASMS  OF  THE  LIVER. 

Malignant  Formations:  Carcinoma. — Primary  carcinoma  of  the 
liver  is  rather  rare.  It  is  estimated  that  5  per  cent,  of  all  cases 
of  hepatic  carcinoma  have  originated  in  this  organ.  Etiologically, 
no  further  details  can  be  adduced.  It  is  possible  that  single  or 
repeated  trauma  of  the  hepatic  region  favors  the  occurrence  of 
primary  hepatic  carcinoma. 

The  starting  point  of  primary  carcinoma  of  the  liver  is  usually 
the  epithelium  of  the  gall  ducts,  whence  a  cylindric  epithelial 
form  of  the  neoplasm  develops.  Scirrhous  and  medullary  car- 
cinomata  of  the  liver  occur  as  nodules  of  varying  sizes  or  as  infil- 
trations. The  nodular  form  occurs  either  as  a  solitary  roundish 
tumor  up  to  the  size  of  an  infant's  head,  and  surrounded  by  liver 


NEOPLASMS  OF  THE  LIVER  601 

tissue,  or  as  numerous  smaller  nodules  which  traverse  the  hepatic 
tissue  more  or  less  densely.  Adhesions  with  other  organs  occur 
but  rarely.  The  infiltrating  carcinomata  invade  diffusely  the 
entire  liver,  causing  considerable  enlargement  and  imparting  to 
the  cross-section  a  lobular  appearance. 

Secondary  carcinoma  exhibits  a  great  variety  of  form  and  his- 
tologic structure,  according  to  the  character  of  the  mother  tumor. 
The  tumor  cells  reach  the  liver  through  the  portal  vein  in  carcinoma 
of  the  abdominal  organs  and  particularly  of  the  female  genitals. 
Metastases  spread  by  the  hepatic  artery  from  carcinoma  of  the 
esophagus,  mamma?,  and  other  organs.  In  many  cases  carcinoma 
of  the  stomach,  intestine  and  gall  bladder  spreads  immediately 
to  the  liver.  In  hepatic  carcinoma,  aside  from  the  growth  itself, 
there  is  usually  a  considerable  increase  of  connective  tissue  in  the 
liver  and  more  or  less  pronounced  atrophy  and  fatty  degeneration 
of  its  parenchyma. 

Sarcoma. — Sarcoma  of  the  liver  occurs  primarily  or  secondarily, 
although  the  primary  form  is  of  even  less  frequent  occurrence  than 
primary  carcinoma.  The  sarcomata  are  usually  spindle-cell  or 
round-cell  forms.  Melanosarcoma  of  the  liver  is  a  very  rare  occur- 
rence. As  in  the  case  of  secondary  carcinoma,  secondary  sarcoma 
exhibits  widely  differing  structures  according  to  that  of  the  mother 
growth.  Like  carcinoma,  too,  it  assumes  either  a  nodular  or  a 
diffusely  infiltrated  form.  As  a  rule  it  growTs  more  rapidly  than 
carcinoma,  and  occurs  in  the  young  as  well  as  in  persons  of  more 
mature  years. 

The  neoplasms  develop  gradually  and  in  the  early  stages  do  not 
give  rise  to  any  symptoms.  Later  on,  dyspeptic  manifestations 
appear — anorexia,  irregular  stools,  lassitude  and  weakness,  ner- 
vousness and  sleeplessness.  In  the  further  course,  emaciation 
progresses  rapidly.  The  complexion  is  sallow,  the  sclera?  often 
show  icteric  discoloration,  and  jaundice  is  not  a  raFe  complication. 
Occasionally  there  is  pain  of  varying  intensity.  All  these  mani- 
festations may  appear  quite  suddenly.  The  liver  feels  more  or  less 
enlarged,  indurated,  or  nodular,  according  to  the  development 
and  location  of  the  tumor.  The  appearance  of  more  or  less  pro- 
nounced jaundice  depends  upon  the  tumors  spreading  to  the  biliary 
ducts.  When  the  portal  circulation  is  impeded,  ascites  will  develop. 
The  spleen  is  usually  not  enlarged.  Fever  may  result  from  disin- 
tegration or  ulceration  of  the  nodules.  Should  metastases  of  the 
peritoneum  or  pleura  occur,  they  may  lead  to  right-sided  pleuritis 
with  corresponding  symptoms.  Perforations  may  occur  into  the 
free  abdominal  cavity.  In  case  of  simultaneous  severe  cirrhosis  of 
the  liver  there  may  be  hemorrhages  from  the  esophagus,  stomach, 
and  intestine. 

The  duration  of  the  affection  is  estimated  at  from  twelve  to 
eighteen  months,  sarcoma  usually  causing  a  more  rapidly  fatal 


602  DISEASES  OF  THE  LIVER 

termination  than  carcinoma.  At  the  onset  of  the  disease  the 
diagnosis  is  not  always  easy,  because,  aside  from  other  hepatic 
affections,  hypertrophic  cirrhosis,  echinococci  and  syphilis  have  to 
be  considered. 

Treatment  of  Malignant  Growths.- — The  treatment  is  purely  symp- 
tomatic in  the  endeavor  to  maintain  the  strength  of  the  patient 
as  long  as  possible  by  abundant  diet,  to  regulate  the  gastro-intestinal 
function,  to  relieve  the  pain  by  narcotics  and  cold  and  warm  com- 
presses, and,  in  the  presence  of  jaundice,  to  relieve  the  intolerable 
itching  of  the  skin.  The  diet  should  be  governed  according  to  the 
protective  principles  which  apply  to  gastro-intestinal  affections  in 
general.  Surgical  treatment  has  been  attempted,,  though  of  course 
with  negative  results.  In  one  instance  the  left  hepatic  lobe  was 
totally  resected  for  carcinoma. 

Benign  Neoplasms. — Fibroma. — Fibroma  of  the  liver  is  rare,  and 
the  tumors  seldom  attain  to  a  size  which  is  likely  to  cause  sub- 
jective symptoms. 

Angioma. — Angioma,  as  a  rule,  does  not  attain  to  more  than 
hazel-nut  size,  and  can  only  be  discovered  at  autopsy. 

Cysts. — Cysts  occur  here  and  there  from  congenital  occlusion 
of  the  bile  ducts,  but  are  not  of  any  clinical  importance. 

PARASITES  OF  THE  LIVER. 

Echinococci. — Echinococci  in  the  human  being  preponderate  in 
the  liver  and  develop  from  the  embryos  of  the  Taenia  echinococcus 
which  exists  in  sheep  and  dogs.  When  they  find  their  way  into 
the  gastro-intestinal  canal  their  outer  walls  are  dissolved  by  the 
digestive  juice,  and  the  liberated  embryo  travels  through  the  diges- 
tive organs  into  the  circulation,  whence  it  most  frequently  migrates 
to  the  liver  and  here  grows  into  the  fully  developed  parasite.  Prob- 
ably the  chitin  hooks  of  the  embryo  penetrate  the  tissues,  and  the 
embryos,  once  in  the  liver,  develop  into  cysts  of  varying  sizes. 
The  cystic  wall  consists  of  a  large  number  of  parallel  chitin  layers; 
it  is  very  thin,  bluish  white  and  transparent.  The  inner  surface 
harbors  small,  bud-like  structures,  or  scolices,  from  which  new, 
sexually  mature  taenia?  develop.  The  cyst  is  filled  with  a  limpid, 
non-albuminous,  uncolored  liquid,  which  contains  succinic  acid. 
More  or  less  numerous  daughter  cysts  float  about  in  this  fluid, 
which  again  possess  scolices  with  four  suckers  each  and  two  coro- 
niform  rows  of  hooks.  The  size  of  the  echinococcus  cyst  may  vary 
from  that  of  a  pea  to  that  of  a  man's  head.  The  right  hepatic 
lobe  is  oftener  involved  than  the  left.  The  shape  of  the  liver 
may  be  considerably  changed  by  the  presence  of  large  cysts;  its 
increase  in  size  may  be  considerable,  reaching  downward  far  into 
the  abdomen  and  upward  into  the  pleura.  In  some  cases  the 
echinococcus  cysts  look  as  if  they  were  attached  to  the  liver  by 


PARASITES  OF  THE  LIVER  G03 

pedicles.    The  hepatic  parenchyma  in  the  neighborhood  of  the 

cyst  atrophies  more  or  less,  according  to  the  size  of  the  cyst.  The 
bile  ducts  are  often  compressed  by  the  tumor,  with  resulting 
jaundice.  The  bloodvessels,  too,  may  be  so  greatly  compressed 
as  to  occasion  portal  stasis.  Circumscribed  or  diffuse  inflammation 
with  adhesions  may  develop  in  the  neighborhood  of  the  cysts. 
The  sac  often  communicates  with  the  bile  ducts,  causing  inflam- 
mation of  the  biliary  system  and  abscesses.  Occasionally  a  cyst 
may  be  evacuated  through  the  bile  ducts.  Again,  large  blood- 
vessels may  become  eroded  and  bleed  into  the  cyst,  and  phlebitis 
and  pyemia  follow.  Should  the  echinococcus  continue  to  grow, 
the  hepatic  parenchyma  will  be  more  and  more  destroyed  and  the 
neighboring  organs  endangered  by  the  possibility  of  the  cyst  grow- 
ing into  the  pleura  and  thus  displacing  the  lungs  and  heart.  Per- 
foration may  also  occur  into  the  right  lung,  the  pericardium,  the 
abdominal  cavity,  the  digestive  organs,  the  vena  cava,  or  the 
renal  pelvis.  Perforation  into  the  thoracic  cavity  is  the  most 
frequent.  As  the  echinococcus  grows  older,  the  cystic  walls  con- 
tinue to  become  thicker  and  firmer.  If  the  walls  are  capable  of 
great  resistance,  or  if  external  obstacles  prevent  further  growth 
of  the  echinococcus,  the  latter  may  perish.  In  that  case  the  cystic 
contents  usually  become  ulcerative,  or  form  a  pulpy  mass  con- 
sisting of  fat  drops,  remnants  of  daughter  cysts,  detritus,  and 
cholesterol  crystals,  in  which  the  circular  rows  of  hooks  can  still 
be  found. 

Symptoms. — Small  cysts  do  not  at  first  cause  any  symptoms. 
As  they  grow  larger  they  give  rise  to  clinical  symptoms  correspond- 
ing to  the  location  of  the  cysts,  including  of  course  the  possibility 
of  displacement  of  neighboring  organs.  Sometimes  the  cyst  can 
be  directly  felt.  There  is  fluctuation  and  the  so-called  hydatid 
sensation,  elicited  on  palpation  when  there  are  many  daughter 
cysts.  Occasionally  there  is  jaundice.  Patients  have  the  sensa- 
tion of  fulness  and  tension  in  the  hepatic  region,  with  slight  pains 
or  none.  On  the  other  hand,  when  there  are  inflammatory  processes 
in  the  cyst,  considerable  pain  and  fever  are  likely  to  arise.  With 
the  continued  growth  of  the  cyst  the  patient  loses  flesh  and  strength, 
and  death  ensues  more  or  less  rapidly.  Spontaneous  cures  have 
been  reported,  and  they  are  feasible  wrhen  the  cyst  is  evacuated 
into  the  intestine  through  the  bile  ducts.  The  affection  usually 
lasts  three  years. 

Diagnosis. — The  diagnosis  must  exclude  hepatic  abscess,  car- 
cinoma of  the  liver,  subphrenic  abscess,  hydronephrosis,  and  pleu- 
ritis.  The  differential  diagnosis  is  by  no  means  easy  under  certain 
circumstances.  It  is  comparatively  easy  when  by  test  punctures 
the  characteristic  fluid  containing  succinic  acid  and  hooks  can  be 
obtained.  This  procedure  is  not  devoid  of  danger,  for  the  punct- 
ure may  not  readily  close,  and  cases  have  been  observed  where 


604  DISEASES  OF  THE  LIVER 

cystic  fluid  has  oozed  out,  leading  to  fatal  peritonitis.  The  presence 
of  echinococci  may  be  demonstrated  by  the  complement-fixation 
test. 

Treatment. — As  a  prophylactic  measure,  infection  with  taenia 
embryos  from  sheep  and  dogs  should  be  avoided  to  the  utmost. 
The  kissing  of  dogs,  in  view  of  the  possibility  of  echinococcus 
infection,  is  a  very  dangerous  habit.  Internal  remedies  for  the 
developed  cysts,  there  are  none.  The  only  appropriate  treatment 
is  surgical. 

Echinococcus  MuItHocularis. — A  much  rarer  form  than  the  above 
is  an  echinococcus  tumor  which  is  distinguished  by  the  fact  that 
the  daughter  cysts  develop  outside  of  the  original  cyst  by  mutual 
contact,  assuming  a  honeycomb  position  and  forming  a  tumor 
of  varying  size  which  is  covered  by  a  hard  capsule  and  firmly 
adherent  to  the  adjacent  parts.  The  various  component  cysts  are 
filled  with  a  bile-like,  yellow  fluid,  which  seldom  contains  hooks 
and  scolices.  The  substance  becomes  hard  and  mortar-like  by 
inspissation.  Necrotic  points  develop  in  the  interior  of  the  cyst, 
which  is  more  often  found  in  the  right  than  in  the  left  lobe  of  the 
liver.  In  this  form  of  echinococcus  cyst,  jaundice  is  of  frequent 
occurrence  and  appears  early,  and  there  is  considerable  connective- 
tissue  proliferation  in  the  hepatic  parenchyma.  The  surface  of 
the  liver  is  gibbous  and  the  organ  itself  considerably  enlarged,  with 
the  result  that  the  affection  is  very  often  mistaken  for  malignant 
hepatic  tumor.  The  tumor  may  attain  to  considerable  dimensions, 
with  manifestations  similar  to  those  which  occur  in  cirrhosis — 
hemorrhage  from  the  stomach,  intestine,  skin  and  mucosa,  as  well 
as  enlarged  spleen.  The  patient's  life  may  be  spared  for  several 
years,  but  sooner  or  later  the  cyst  proves  fatal. 

Other  Parasites. — In  tropical  countries,  infections  of  the  liver 
occur  by  means  of  the  following  parasites:  ascarides,  Distoma 
hepaticum,  Distoma  hematobium  (Bilharzia  sanguinis),  Pantasto- 
murn  denticulatum,  coccidia. 

FATTY  LIVER. 

The  fatty  contents  of  the  liver,  which  normally  amount  to  from 
1  to  5  per  cent.,  may  pathologically  increase  to  as  much  as  30  to 
40  per  cent.  Either  the  fat  penetrates  into  the  liver  from  without 
(fatty  infiltration)  or  there  is  fatty  degeneration  of  the  hepatic 
cells  themselves;  as  a  rule  both  modes  occur  simultaneously. 

Etiology. — Fatty  liver  is  not  an  idiopathic  affection,  but  occurs 
in  conjunction  with  numerous  other  pathologic  conditions.  In 
cases  of  general  adiposity  there  is  always  fatty  liver.  A  large 
number  of  chemical  agents,  such  as  arsenic,  camphor,  alcohol,  car- 
bon dioxid,  mercury,  and  particularly  phosphorus,  tend  to  the 
deposition  of  fat  in  the  liver,  in  the  presence  of  toxemia.     Fatty 


NEURALGIA  OF  THE  LIVER  605 

degeneration  in  aente  yellow  atrophy  of  the  liver  is  a  well-known 
pathologic  condition.  Fatty  liver  also  oeenrs  in  infections  dis- 
eases and  chronic  digestive  disturbances.  It  is  likewise  a  well- 
known  fact  that  carcinoma,  tuberculosis  and  leukemia  are  conducive 
to  fatty  liver. 

Pathology. — A  fatty  liver  retains  its  original  shape,  being  uni- 
formly enlarged  in  all  diameters,  with  a  smooth  surface,  and  is 
yellowish-white  in  color.  Its  consistency  is  soft  and  doughy. 
Cross-section  admits  of  the  removal  of  a  considerable  quantity  of 
fat  with  a  knife.  Microscopically,  the  periphery  of  the  hepatic  lobe 
and  the  hepatic  cells  themselves  are  seen  to  contain  abundant 
quantities  of  fat  or  fat  drops.  The  fatty  infiltrated  cells  retain 
their  shape,  protoplasm  and  nucleus  practically  unchanged,  while 
nucleus  and  protoplasm  of  the  degenerated  fatty  cells  are  consider- 
ably damaged  and  inclined  to  atrophy. 

Treatment. — The  treatment  is  concerned  with  removing  or  modi- 
fying the  underlying  causes. 

HEPATOPTOSIS. 

Floating  or  migratory  liver  is  usually  a  part  manifestation  of 
a  general  gastroenteroptosis  (see  page  568).  Just  as  the  stomach 
and  intestine  may  prolapse  by  the  loosening  of  their  ligaments,  so 
may  the  liver  be  affected  by  stretching  and  loosening  of  its  sup- 
porting ligaments  (coronary  ligament).  Tight  lacing,  pregnancy, 
umbilical  hernia  or  sudden  emaciation  may  cause  relaxation  of 
this  ligament. 

The  movable  liver  can  be  easily  demonstrated  (provided  the 
abdominal  walls  are  not  unduly  thick)  in  the  shape  of  a  large 
movable  and  palpable  tumor  in  the  upper  right  abdominal  region 
which,  in  the  nature  of  things,  can  only  be  the  liver.  It  is  a  par- 
ticularly characteristic  sign  that  the  displaced  liver  sinks  back 
into  the  recesses  of  the  diaphragm  when  the  patient  assumes  the 
dorsal  decubitus.  In  running  or  walking  the  patient  experiences 
a  sensation  of  heaviness,  traction  and  tension  in  the  hepatic  region. 
Other  symptoms  are  dyspnea,  constipation,  meteorism,  and  hemor- 
rhoids. 

Treatment.— For  therapeutic  purposes  the  wearing  of  a  well- 
fitting  abdominal  bandage  is  to  be  taken  into  consideration.  The 
treatment  is  directed  against  the  constitutional  habitus  enterop- 
toticus  (see  Chapter  XXX). 

NEURALGIA  OF  THE  LIVER. 

It  appears  that  purely  nervous  pains  may  occur  in  the  liver. 
The  hepatic  nerves  emanate  from  the  abdominal  sympathetic, 
accompanying  the  hepatic  arteries  (hepatic  plexus).     As  a  matter 


606  DISEASES  OF  THE  LIVER 

of  course  the  diagnosis  of  neuralgic  pains  in  the  liver  can  never 
be  made  with  certainty.  We  have  reports  of  colicky  pains  in 
the  liver,  observed  in  hysterical  individuals,  which,  in  default 
of  any  objective  findings,  have  been  regarded  as  neurotic.  The 
paroxysms  of  pain  are  quite  similar  to  those  of  gallstone  colic. 
Occasionally  paroxysms  of  this  kind  occur  in  conjunction  with 
menstruation  as  well  as  with  various  neurasthenic  or  neuralgic 
symptoms. 

The  object  of  the  treatment  is  to  remove  any  possible  neuras- 
thenic or  hysterical  underlying  affection,  and  to  apply  soothing 
remedies,  such  as  the  bromids,  morphin  and  heat,  when  paroxysm 
occurs. 


CHAPTER  XXXII. 

DISEASES  OF  THE  BILE  DUCTS  AND  GALL  BLADDER. 

Cholangitis;  Cholecystitis;  Catarrhal  Jaundice;  Hemorrhage; 
Neoplasms;  Dilatation;  Parasites;  Gallstones. 

INFLAMMATION  OF  THE  BILE  DUCTS  AND  GALL 
BLADDER. 

Cholangitis  and  Cholecystitis. — Inflammation  of  the  bile  ducts 
and  gall  bladder  is  usually  due  to  microorganisms  —  Bacillus 
coli,  typhoid  and  paratyphoid  bacilli,  pneumococci,  streptococci, 
staphylococci,  cholera  organisms,  and  tubercle  bacilli.  As  a  rule 
normal  bile  is  sterile.  The  manner  in  which  the  choledochus 
inosculates  into  the  intestine  prevents  the  intestinal  contents  and 
intestinal  bacteria  from  entering  the  duct.  If  the  organisms 
mentioned  above  should  find  access  to  the  bile  ducts  under  patho- 
logic conditions,  either  from  the  intestine  or  from  the  blood,  certain 
predisposing  factors  must  be  present  in  order  that  they  may  display 
their  infectious  properties.  Such  factors  are:  abnormality  of  the 
epithelium  of  the  ducts,  changes  in  the  circulation,  kinking,  occlu- 
sion or  compression  of  the  ducts.  Inflammation  of  these  ducts 
may  also  occur  independently  of  bacteria,  from  portal  stasis,  pas- 
sive hyperemia  of  the  liver,  or  parasites  invading  the  latter  from 
the  intestine. 

Pathology. — The  pathologic  changes  in  simple  cholangitis  consist 
in  swelling,  hyperemia  and  reddening  of  the  mucous  membrane, 
and  loosening  of  the  epithelium.  This  causes  more  or  less  constric- 
tion of  the  ducts  and,  consequently,  biliary  stasis.  As  the  affec- 
tion proceeds  the  bile  ducts  become  wholly  or  in  part  filled  with  a 
viscid  or  grayish-yellow  mucous  secretion,  containing  numerous 
desquamated  cylindric  epithelia.  These  changes  are  most  pro- 
nounced in  the  larger  bile  ducts,  and  especially  in  the  choledochus 
and  cystic  duct,  and  in  most  cases  edema,  hyperemia  and  abundant 
mucus  are  to  be  found  at  the  junction  of  the  common  bile  duct 
and  the  duodenum.  In  a  case  of  catarrhal  jaundice  recently 
reported  there  was  infiltration  and  swelling  of  the  lymphadenoid 
tissue  in  the  wall  of  the  common  bile  duct  similar  in  appearance 
to  that  seen  in  inflammation  of  the  vermiform  appendix.  If 
the  choledochus  remains  occluded  for  any  considerable  length  of 
time  this  condition  will  lead  to  a  more  or  less  extensive  enlarge- 
ment of  the  tributary  bile  ducts  and  of  the  gall  bladder.  At  the 
same  time  the  liver  is  swollen.     An  acute  catarrh  will  persist  for 


608     DISEASES  OF  THE  BILE  DUCTS  AND  GALL  BLADDER 

two  or  three  weeks  and  undergo  resolution  without  leaving  any 
permanent  changes.  Should  the  affection  become  chronic,  as  in  the 
presence  of  stones,  parasites,  neoplasms,  etc.,  the  ducts  gradually 
become  more  distended  and  thickened,  and  filled  with  a  purulent, 
mucous,  grayish-yellow  fluid.  There  may  also  be  grave  anatomic 
changes,  ulcerations,  etc.,  or  even  obliteration  of  the  bile  ducts. 
The  pathologic  changes  in  simple  cholecystitis  are  much  the  same, 
except  that  occlusion  of  the  gall  bladder  is  more  apt  to  occur  than 
occlusion  of  the  bile  ducts,  which  tend  to  stretch  under  the  inner 
pressure.  If  cholecystitis  runs  a  chronic  course  it  may  assume 
a  purulent,  ulcerative  character.  There  also  is  a  possibility  of 
the  cystic  contents  being  absorbed,  leading  to  shrinkage  and  final 
obliteration  of  the  gall  bladder  and  cystic  duct.  Or  the  inflam- 
mation may  spread  from  the  mucous  membrane  to  the  other 
strata  of  the  gall  bladder  and  organs  in  its  vicinity  (stomach, 
intestine),  causing  inflammatory  processes  and  adhesions.  The 
pylorus  is  often  well  fixed  to  the  right  of  the  median  line.  This  is 
the  so-called  "gall-bladder  position  of  the  stomach"  which  is 
easily  demonstrable  by  the  bismuth  meal  and  the  Roentgen  ray. 
(See  page  150  and  Plate  XXI,  Fig.  2.) 

Cholecystitis  will  often  alter  the  outline  and  the  size  of  the  liver. 
The  right  lobe,  as  a  result  of  the  gall-bladder  infection,  becomes 
hypertrophied,  either  in  spherical  form  over  the  site  of  infection  or 
from  this  point  downward  and  to  the  right,  forming  a  tongue-like 
enlargement  (known  as  Riedel's  lobe)  which  may  extend  from  the 
median  line  to  the  extreme  margin  of  the  liver  to  the  right.  While 
in  pronounced  cases  the  right  lobe  is  distinctly  palpable,  that 
portion  of  the  liver  which  lies  to  the  left  of  the  median  line  cannot 
be  detected  by  the  sense  of  touch.  Sensitiveness  of  the  affected 
region  is  manifested  by  rigidity  of  the  right  rectus  muscle. 

Inflammatory  processes  of  the  gall  bladder  or  its  adjacent  struc- 
tures may  lead  to  the  formation  of  adhesions.  The  most  common 
of  these  adhesions  implicate  the  duodenum  or  the  pyloric  end  of 
the  stomach,  or  both.  It  has  been  found  that  deep  continuous 
pressure  to  the  right  of  the  spinal  column  between  the  seventh 
and  eleventh  ribs  will  induce  pain  in  case  of  gall-bladder  adhesion. 
According  to  Friedman,  these  pressure  points  are  pathognomonic 
of  pericholecystic  adhesions  with  or  without  cholecystitis.  (For 
Naunyn's  and  Murphy's  signs  for  cholecystitis  see  page  619.) 

Symptoms. — The  symptoms  of  cholangitis  and  those  of  cholecys- 
titis are  very  much  alike.  In  most  cases  of  cholecystitis  the  bile 
ducts  are  simultaneously  affected.  If  the  acute  inflammation  is 
at  all  extensive,  it  will  cause  pain  in  the  region  of  the  gall  bladder 
and  enlargement  of  this  organ  and  of  the  liver.  According  to  the 
intensity  of  the  inflammation  and  the  extent  of  the  biliary  stasis, 
the  pains  and  hepatic  hypertrophy  will  vary.  At  times  there  may 
be  colicky  paroxysms  simulating  gallstone  colic.     At  any  rate  the 


CHOLANGITIS  AND  CHOLECYSTITIS  609 

diagnosis  may  be  doubtful  until  the  appearance  of  jaundice,  a 
characteristic  symptom,  which  points  distinctly  to  the  bile  ducts 
as  the  seat  of  the  trouble.  The  pathologic  picture  then  presented 
is  usually  characterized  as  catarrhal  jaundice,  and  it  is  assumed 
that  this  affection  is  caused  by  the  spreading  of  gastric  or  intes- 
tinal catarrh  to  the  bile  ducts.  It  often  begins  with  digestive 
disturbances,  anorexia,  nausea,  vomiting,  eructation,  irregular 
stools,  and  slight  fever.  Jaundice,  which  develops  slowly,  is  dis- 
tinctly seen  in  the  conjunctivae,  and  later  also  in  the  skin,  in  chang- 
ing intensity.  Concomitant  manifestations,  consisting  of  retarded 
pulse  and  itching  of  the  skin,  will  make  their  appearance.  In  many 
cases,  however,  gastric  and  intestinal  manifestations  are  entirely 
absent,  and  in  these  cases  the  etiology  of  the  jaundice  is  not  always 
clear.  There  is  a  clear  connection  between  cholecystitis  and 
myocardial  incompetence.  A  weak  myocardium  is  the  rule  in  all 
gall-bladder  affections.  The  assumption  has  recently  been  favored 
that  there  is  such  a  thing  as  functional  jaundice — that  the  pigment 
components  of  the  bile  and  the  components  which  cause  pruritus 
are  not  produced  at  the  same  time  or  place,  perhaps  running  in 
different  directions,  with  the  consequence  that  the  entire  bile-pro- 
ducing apparatus  and  the  hepatic  function  are  interfered  with. 
This  conclusion  has  been  drawn  from  the  fact  that  at  times  itching 
precedes  jaundice  by  several  days  or  persists  after  the  jaundice 
has  subsided,  and  from  the  further  fact  that  in  some  cases  of 
jaundice  there  is  no  itching,  the  substances  that  cause  it  having, 
presumably,  not  been  produced  at  all.  It.  is  also  a  striking  fact 
that  catarrhal  jaundice  not  infrequently  occurs  endemically.  Tak- 
ing into  consideration  the  lymphadenoid  affection  of  the  choled- 
ochus  referred  to  above,  this  might  give  color  to  the  idea  that 
jaundice  originates  hematogenously  from  infection,  like  the  fre- 
quent occurrence  of  appendicitis  after  tonsillitis.  As  the  catarrh 
subsides,  the  symptoms  likewise  gradually  disappear,  jaundice 
and  its  accompaniments  recede,  the  feces  (which  were  clay-colored) 
resume  their  normal  color,  and  the  enlarged  liver  undergoes  invo- 
lution. However,  nearly  every  prolonged  case  of  jaundice  causes 
weakness,  emaciation,  and  anemia — a  fact  wdiich  is  explained  by. 
the  injurious  influence  exerted  by  the  biliary  acids  upon  the  red 
blood-corpuscles,  depriving  them  of  hemoglobin. 

When  there  is  biliary-duct  obstruction  inducing  the  back  flow  of 
bile  into  the  liver,  serious  damage  is  done  to  the  liver  cells.  Necrosis 
and  connective  tissue  change  take  place.  It  is  assumed  that  the 
destruction  of  the  liver  tissue  depends  upon  the  chronicity  of  the 
biliary  stasis.  The  longer  a  clinical  jaundice  continues,  the  more 
damage  is  done  to  the  liver. 

Among  the  sequelse  of  catarrhal  jaundice,  gallstone  formation 
ranks  first,  and  there  is  no  doubt  that  concrements  are  often  formed 
in  the  bile  in  cholangitis.     A  serious  complication  consists  in  the 
39 


610     DISEASES  OF  THE  BILE  DUCTS  AND  GALL  BLADDER 

agglutination  of  the  common  bile  duct,  which  may  occur  through 
loss  of  its  epithelium  or  as  a  result  of  ulcerative  processes,  leading 
to  chronic  biliary  stasis.  This  may  cause  an  enormous  dilatation 
of  the  bile  duct  and  gall  bladder,  serious  injury  to  the  liver,  emacia- 
tion, and  cachexia.  If  the  obliteration  is  confined  to  the  cystic 
duct,  there  will  be  dropsy  of  the  gall  bladder;  if  branches  of  the 
hepatic  duct  are  involved,  there  may  be  partial  atrophy  of  the 
hepatic  tissue.  The  test-diet  stool  is  characteristic  (see  Chapter 
IV).  When  there  is  an  obstruction  of  the  common  duct  the  duo- 
denal contents  are  typical  (see  page  109). 

The  affection  lasts  from  three  to  four  weeks,  in  light  cases  from 
ten  to  fourteen  days;  cases,  however,  have  been  observed  which 
continued  for  three  or  four  months.  As  a  general  rule  the  prog- 
nosis is  good,  unless  the  chronic  changes  above  referred  to  should 
supervene. 

Cholemia  is  occasionally  a  family  affection,  but  the  pathology 
of  this  form  is  not  clearly  understood.  The  usual  cause  is  an 
angiocholitis,  or  some  obstacle  preventing  the  normal  flow  of  bile, 
which  induces  hypertrophy  of  the  liver,  with  urobilinuria.  Famil- 
ial cholemia  can  be  separated  into  two  stages:  the  first  being  a 
long  one  of  compensation,  well  borne  by  the  patient,  the  second 
stage  one  of  broken  compensation  and  resulting  complications. 
During  the  first  stage  hemorrhages  often  occur,  as  epistaxis  or 
menorrhagia.  The  functional  disturbance  of  the  liver  is  apt  to 
cause  the  violent  attacks  of  migraine  which  are  seen  in  cholemics. 

Diagnosis. — Examination  of  the  duodenal  contents  should  be 
made  in  all  cases  of  suspected  cholangitis  and  cholecystitis  (see  pages 
104  and  109).  It  furnishes  direct  diagnostic  evidence  of  the  beginning 
'  of  biliary  stasis,  the  precursor  of  biliary  disease.  To  drain  the  biliary 
system,  the  duodenum  should  be  douched  with  90  Cc.  of  a  30-per- 
cent, solution  of  magnesium  sulphate,  which  relaxes  the  sphincter 
of  the  common  duct  and  contracts  the  gall  bladder.  In  a  few  min- 
utes there  is  a  free  flow  of  bile  in  the  duodenum.  Lyon1  demon- 
strated that  the  first  bile  collected  is  from  the  common  duct,  cystic 
duct,  and  hepatic  ducts.  It  soon  becomes  vividly  golden-yellow  in 
color  and  of  a  syrupy  consistence.  This  is  followed  by  a  second  and 
darker  bile,  presumably  from  the  gall  bladder;  and  then  comes  a 
thinner  common  yellow  bile  that  has  been  freshly  secreted  by  the 
liver  cells.  Any  deviation  from  this  normal  secretion  means  patho- 
logic change  in  the  biliary  system.  It  is  therefore  important  that 
attention  be  given  to  the  gross  appearance  of  the  bile,  such  as  color, 
consistency,  viscosity,  transparency,  and  turbidity.  Especial  study 
should  be  made  microscopically  for  the  presence  of  bile-stained 
epithelium,  pus,  leukocytes,  red  blood-corpuscles,  crystals,  concre- 
tions, mucus,  and  bacteria. 

1  B.  B.  Vincent  Lyon:  The  Need  of  Early  Diagnosis  and  Treatment  of  Chole- 
doehitis,  Cholecystitis  and  Cholelithiasis,  Annals  of  Medicine,  July,  1920. 


CHOLANGITIS  AND  CHOLECYSTITIS  611 

In  a  report  of  his  pathologic  findings  in  1000  gall-bladder  cases 
Smithies  declares  that  in  nearly  .">()  per  cent,  pericholeeystic  adhe- 
sions were  found,  in  which  the  duodenum  was  usually  involved, 
inducing  displacement  and  distortion  of  the  latter.  The  Roentgen 
ray  will  not  always  show  this  abnormality,  because  the  opaque  meal 
in  the  stomach  overlaps  the  descending  and  transverse  portions  of 
the  duodenum.  Palefski1  utilizes  an  especially  long  duodenal  tube 
under  such  conditions  to  visualize  the  duodenum  by  means  of  the 
Roentgen  ray.  Displacements  and  angulations  due  to  periduodenal 
adhesions  can  thus  be  recognized.  The  course  of  the  duodenal  tube 
follows  the  lesser  curvature  of  the  stomach  through  the  pylorus  into 
the  jejunum.  Normally  the  roentgenogram  shows  the  tube  in  the 
duodenum  as  an  unaltered  horseshoe-shaped  curve.  Distortion  of 
this  duodenal  curve  indicates  displacement  and  adhesions  of  the 
duodenum  suggestive  of  gall-bladder  pathology. 

Traction  on  the  umbilicus  in  the  direction  of  the  pubes  often 
induces  pain  over  the  gall-bladder  region  (see  page  619.) 

Hemocones. — Hemocones  provide  an  indirect  means  of  ascer- 
taining the  existence  of  bile  acid  retention.  They  are  for  the  most 
part  granules  of  fat,  emulsified  in  the  small  intestine,  absorbed 
and  carried  into  the  general  circulation  through  the  thoracic  duct. 
They  are  easily  demonstrable  by  the  ultramicroscope  as  tiny  spark- 
ling granulations,  animated  by  constant  well-marked  Brownian 
movement.  To  detect  them,  the  patient  is  given  an  ounce  of 
butter  on  a  slice  of  bread.  Three  hours  later  a  drop  of  blood  is 
taken  from  the  finger,  placed  on  a  slide  and  gently  squeezed  with 
a  cover-glass.  The  hemocones  can  be  readily  seen  in  the  open 
spaces  with  the  ultramicroscope.  They  are  found  in  the  blood 
for  four  or  five  hours  in  proportion  to  the  amount  of  fat  ingested. 
In  cases  of  obstruction,  the  bile  not  entering  the  duodenum,  no 
hemocones  are  found  in  the  blood  after  the  ingestion  of  butter. 
When  it  is  desired  to  ascertain  the  state  of  the  secretion  of  bile 
salts,  the  finding  of  hemocones  indicates  that  the  ingested  butter  has 
been  absorbed  after  due  elaboration  by  the  bile  salts.  A  negative 
result  would  point  to  defective  absorption  of  fats  and  inferentially 
to  the  lack  of  bile  salts  in  the  duodenum. 

Treatment. — Experience  has  shown  that  catarrhal  jaundice  is 
most  favorably  influenced  by  Carlsbad  mineral  waters,  though 
there  is  no  evidence  that  these  waters  have  any  cholagogue  action; 
their  beneficial  effect  is  probably  due  to  their  anticatarrhal  proper- 
ties. Furthermore,  the  alkalis  contained  in  the  Carlsbad  waters 
will  protect  the  red  blood-corpuscles  from  the  hemolytic  action  of 
the  biliary  acids  in  jaundice  by  raising  their  power  of  resistance. 
The  Carlsbad  cure  is  best  taken  in  Carlsbad  itself,  but  may  also 
be  carried  out  at  home  with  Carlsbad  Muhlbrunnen  or  Schloss- 

1  I.  O.  Palefski:  Intubation  and  Visualization  of  the  Duodenum  with  the  Duode- 
nal Tube,  Journal  of  the  American  Medical  Association,  December  4,  1920. 


612     DISEASES  OF  THE  BILE  DUCTS  AND  GALL  BLADDER 

brunnen.  The  treatment  should  not  commence  until  after  gastric 
or  intestinal  symptoms  have  been  relieved.  It  is  as  follows:  In 
the  morning  200  Cc.  (7  ounces)  of  the  water,  heated  to  90°  F.,  is 
taken  upon  an  empty  stomach,  followed  by  the  same  quantity 
twenty  minutes  later.  Four  hours  after  the  midday  meal  the  same 
quantity  is  ingested  at  the  same  temperature,  and  immediately 
before  retiring  150  Cc.  (5  ounces)  at  a  somewhat  lower  temperature. 
After  a  week  the  temperature  of  the  water  may  be  raised  to  95° 
to  100°  F.  If  indicated,  and  especially  in  constipation,  4  Gm.  (5j) 
of  Carlsbad  sprudel  salt  or  Carlsbad  effervescent  salt  is  added  to 
the  first  glass  of  water.  Sodium  phosphate,  sodium  sulphate  or 
magnesium  sulphate  can  be  given  with  the  same  benefit  (see  page 
284).  Small  doses  of  pulvis  rhei  compositus  likewise  have  a  favor- 
able effect.  While  taking  this  treatment  the  patient  should  not 
walk  much.  The  treatment  should  be  kept  up  for  two  or  three 
weeks  after  the  jaundice  and  the  swelling  of  the  liver  have  dis- 
appeared, and  repeated  about  six  months  later.  In  regard  to 
jaundice,  testing  of  the  urine  for  urobilinogen  is  of  practical  impor- 
tance, because  this  substance  is  often  demonstrable  long  after 
urobilin  has  ceased  to  be.  The  Carlsbad  cure  presupposes  normal 
gastric  motility,  and  any  changes  in  the  circulation  demand  caution. 
Both  quantity  and  temperature  of  the  water  should  be  kept  within 
moderate  limits,  especially  when  the  blood-pressure  is  high. 

Einhorn  found  that  glycerin,  given  in  teaspoonful  doses  three 
times  daily,  exerts  an  antiputrefactive  action  on  the  bile.  This  was 
proved  by  a  study  of  the  bile  after  its  removal  through  the  duodenal 
tube.  Patients  to  whom  glycerin  has  been  given  furnish  a  bile  that 
can  be  kept  from  one  to  two  days.  Without  this  medication  the 
duodenal  secretion  after  exposure  to  the  air  for  a  few  hours  begins 
to  decompose  and  in  the  course  of  six  hours  develops  a  putrid  odor. 

The  following  may  be  given  with  advantage: 

Gm.  or  Cc. 

1$ — Sodii  bicarbonatis 810  oij 

Glycerini 60  0  5ij 

Aquae  destillatse 150)0  §v 

Misce. 

Sig. — Tablespoonful  three  times  a  day,  half  an  hour  before  meals. 

Salicylic  acid  and  hexamethylenamin  have  a  distinct  disinfecting 
action  upon  the  bile  and  probably  a  direct  cholagogue  effect.  The 
polyvalent  combined  bacterial  vaccines  are  valuable  adjuvants. 

The  local  application  of  a  25-per-cent.  solution  of  magnesium 
sulphate  to  the  intestinal  mucosa  causes  a  relaxation  of  the  mus- 
cular wall.  On  the  introduction  of  one  ounce  of  this  solution 
through  the  duodenal  tube  into  the  duodenum,  the  sphincter  of 
the  common  bile  duct  relaxes,  allowing  free  flow  of  bile.  Duodenal 
lavage  with  a  solution  of  magnesium  sulphate  should  be  practiced 
in  all  these  cases.    Thus  non-surgical  drainage  of  the  gall  bladder 


CHOLANGITIS  AND  CHOLECYSTITIS  613 

and  bile  ducts  gives  most  gratifying  results.  This  is  a  simple  process, 
since  we  are  able  to  use  the  duodenal  tube  to  advantage.  With  its 
aid  we  can  apply  medication  directly  to  the  mucous  membrane  of 
the  duodenum  (see  page  104).  By  duodenal  lavage  the  biliary 
apparatus  can  be  thoroughly  drained  (see  page  105). 

The  diet  should  be  absolutely  free  from  irritating  constituents. 
Carbohydrates  should  be  given  in  liberal  quantities  (rice,  farina- 
ceous food,  farinaceous  infant  foods,  dextrinized  flour).  As  to 
fats,  none  but  emulsified  or  easily  emulsifiable  fats  are  allowed — 
which  means  small  quantities  of  butter  and  milk,  because  other 
neutral  fats  cannot  be  emulsified  in  the  absence  of  the  biliary  flow. 
Nor  is  it  advisable  to  allow  large  quantities  of  meat,  because 
putrefactive  processes  may  easily  develop  in  the  intestine  in  stasis 
of  the  septic  bile  and  accompanying  disturbance  of  pancreatic 
function.  For  this  reason  none  but  tender  meat  (veal,  chicken, 
pigeon,  sweetbread)  may  be  given.  Pancreatic  preparations  may 
be  indicated  as  adjuvant  treatment  (see  page  262).  Vegetables 
are  allowed  in  puree  form  and  finely  divided.  The  meals  should 
be  small,  but  frequent. 

Patients  should  have  much  rest  in  bed,  especially  in  the  first 
stages  of  the  affection  and  according  to  the  degree  of  its  intensity. 
Hot  cataplasms  are  applied  to  the  hepatic  region.  The  unpleas- 
ant itching  is  at  times  relieved  by  ablutions  with  diluted  vinegar, 
lemon  juice,  chloroform,  spirit  of  menthol,  or  warm  baths.  Occa- 
sionally the  itching  ceases  after  a  hypodermic  injection  of  pilocarpin. 

As  a  palliative  measure,  Anderson's  powder  is  useful: 


Gm.  or  Cc. 

1$ — Camphoris 6 

Zinci  oxidi 15 

Amyli 30 

Misce. 

Sig.— Dust  lightly  over  skin  with  a  powder  puff. 


0  3iss 

0  §ss 

o  §j 


Suppurative  Cholangitis  and  Cholecystitis. — Etiology. — This  origi- 
nates from  the  same  causes  as  simple  catarrhal  inflammation  and 
occurs  when  the  latter  takes  a  grave  course.  It  may,  however, 
also  occur  in  the  course  of  serious  infectious  diseases  (cholera, 
sepsis,  typhoid),  or  it  may  spread  from  neighboring  inflammations 
and  ulcerations  to  the  bile  ducts  or  gall  bladder.  Mechanical 
causes  such  as  gallstones,  parasites  or  wounds  are  often  the  pre- 
disposing factor,  enabling  the  microorganisms  to  gain  a  foothold. 

Pathology. — The  gall  bladder  is  affected  most  frequently.  It,  as 
well  as  the  diseased  bile  duct,  is  dilated  and  filled  with  a  muco- 
purulent or  ichorous  fluid.  The  mucous  membrane  is  hyperemic, 
incrassated  and  hemorrhagic,  while  fibrinous  inflammations  with 
necrosis  of  the  mucosa  and  ulceration  may  supervene.  The  ulcera- 
tions may  permeate  the  entire  wall  of  the  gall  bladder  or  ducts, 
leading  to  abscesses  of  the  liver,   adhesions  to  the  neighboring 


614     DISEASES  OF  THE  BILE  DUCTS  AND  GALL  BLADDER 

parts,  and  perforation  of  the  gall  bladder.  In  the  course  of  destruc- 
tive processes  in  the  wall  of  the  gall  bladder,  biliary  effusion  into 
the  peritoneal  cavity  is  not  infrequent,  causing  biliary  peritonitis. 
At  autopsy,  microscopic  examination  is  often  necessary  for  the 
detection  of  the  minute  defects  in  the  wall  of  the  gall  bladder  or 
of  the  larger  ducts  through  which  the  bile  has  percolated.  When 
the  gall  bladder  is  filled  with  pus  and  dilated,  we  have  to  deal  with 
an  empyema  of  the  gall  bladder.  The  finding  of  pus  after  aspirating 
the  duodenal  contents  with  the  duodenal  tube  assists  in  an  early 
diagnosis,  providing  the  gall  bladder  is  able  to  discharge  a  specimen 
of  its  contents  into  the  duodenum. 

Symptoms. — At  the  onset  there  is  the  same  picture  as  in  catarrhal 
inflammation.  The  gravity  of  the  affection  does  not  become 
apparent  until  chills  and  fever  occur.  Then  there  is  enlargement 
of  the  gall  bladder  and  pain  in  the  hepatic  region,  although  these 
symptoms  are  also  present  in  other  affections  of  the  gall  bladder, 
calculi,  parasites,  and  tumors.  For  this  reason  the  diagnosis  is 
always  uncertain  until  abscesses,  peritonitis,  perforation  or  pyle- 
phlebitis complicate  the  picture.  Manifestations  of  this  kind,  of 
course,  render  the  prognosis  grave. 

Treatment. — The  treatment  is  directed  largely  to  checking  the 
inflammatory  process  as  far  as  possible  by  rest  in  bed,  application 
of  ice,  mild  lactovegetable  diet,  and  light  laxatives.  When  the 
fever  is  pronounced,  antipyretic  remedies  are  prescribed.  In  col- 
lapse, alcohol  and  the  injection  of  camphor  are  to  be  considered. 
In  all  cases,  however,  where  there  is  a  suspicion  of  infectious  chole- 
cystitis, surgical  measures  should  be  resorted  to  as  soon  as  possible, 
to  prevent  necrosis  and  perforation  of  the  wall  of  the  gall  bladder. 

HEMORRHAGE  INTO  THE  BILE  DUCTS. 

Hemorrhages  into  the  bile  ducts  occur  as  a  result  of  chronic 
hyperemia,  necrosis  of  the  mucosa,  or  trauma.  Aneurysms  of  the 
hepatic  artery  have  also  been  observed  to  perforate  into  the  bile 
ducts.  Any  treatment  in  such  cases  is  out  of  the  question,  because 
they  cannot  be  diagnosticated  during  life. 

NEOPLASMS  OF  THE  BILE  DUCTS  AND  GALL  BLADDER. 

The  most  common  of  these  are  carcinomata,  while  in  rare  cases 
we  find  fibroma,  sarcoma,  cysts,  papilloma,  and  tubercles.  Carci- 
noma occurs  in  the  bile  ducts  in  the  form  of  circumscribed  nodules 
of  the  mucosa  or  as  a  diffuse  infiltration  of  the  latter.  The  mucous 
membrane  may  be  intact,  but  frequently  it  is  ulcerated.  As  the 
neoplasm  continues  to  proliferate,  the  walls  of  the  bile  ducts  become 
rigid  and  thickened,  and  the  lumen  constricted  or  occluded.  Gall- 
stones are  present  in  many  cases.  Carcinoma  of  the  gall  bladder 
occurs  in  a  similar  way  and  is  nearly  always  associated  with  stone 


DILATATION  OF  THE  BILIARY  ORGA.XS  615 

formation,  the  latter  probably  being  antecedent  to  the  develop- 
ment of  the  neoplasm.  Carcinoma  of  the  choledochus  and  of  the 
papilla  of  Vater  has  likewise  been  observed. 

Symptoms. — Neoplasms  of  the  bile  ducts  do  not  cause  any  mani- 
festations unless  they  lead  to  occlusion  of  the  larger  ducts  and  to 
jaundice.  This  is  followed  by  rapidly  increasing  manifestations 
of  biliary  stasis,  swelling  of  the  liver,  and  cachexia.  Carcinoma 
of  the  gall  bladder  is  usually  associated  with  pain  in  that  region, 
which  is  often  persistently  present  and  in  many  cases  resembles 
gallstone  colic.  Gradually,  a  hard  growing  tumor  can  be  palpated 
in  the  gall  bladder.  In  carcinoma  of  the  choledochus,  jaundice 
occurs  without  any  paroxysms  of  pain.  Women  are  more  frequently 
the  subjects  of  these  malignant  growths  than  men. 

Diagnosis. — Carcinoma  of  the  bile  ducts  cannot  be  diagnosticated 
with  certainty,  but  its  presence  may  be  assumed  when  chronic 
jaundice  is  associated  with  carcinomatous  cachexia.  The  affection 
may  last  for  years.  In  carcinoma  of  the  gall  bladder  the  presence 
of  the  distinct  growth  suggests  the  diagnosis,  although  there  is 
a  possibility  of  the  growth  having  started  from  other  organs  in  the 
vicinity  of  the  gall  bladder  without  giving  any  positive  evidence  of 
the  fact.  A  normal  gall  bladder  does  not  lose  its  elasticity.  When 
the  wall  of  a  gall  bladder  has  become  infiltrated  with  leukocytes 
and  thickened,  it  is  non-distensible.  Infection  lessens  the  distensi- 
bility.  So  when  there  is  complete  obstruction  of  the  bile  duct  due 
to  a  carcinoma  at  or  near  the  duodenal  papilla,  or  at  or  near  the 
pancreas,  the  gall  bladder  is  distended  and  a  tumor  is  palpable. 
Courvoisier's  law  applies  here,  that  if  there  is  obstruction  at  the 
common  duct  due  to  malignant  disease  a  tumor  will  be  found  in  the 
region  of  the  gall  bladder.  When  the  gall  bladder  is  small  and 
jaundice  is  present  the  obstruction  is  due  to  stone.  The  hemolytic, 
antitryptic  or  miostagmin  reaction  may  aid  in  the  diagnosis  (see 
page  543).  The  Roentgen  ray  is  often  of  great  assistance  in  the 
diagnosis  (see  Chapter  V). 

Treatment.— This  is  surgical.  The  gall  bladder  degenerated  by 
carcinoma,  together  with  the  adjacent  hepatic  tissue,  must  be 
removed.  Surgery  offers  no  hope  of  cure,  however,  when  there 
are  hepatic  metastases  or  when  the  portal  lymph  gland  is  already 
affected.  Removal  of  carcinoma  of  the  choledochus  or  of  the 
papilla  of  Yater  has  been  successful  in  a  few  cases.  Aside  from  this 
there  is  nothing  left  but  resort  to  palliative  operations,  such  as 
a  biliary  fistula  outward  or  a  fistula  between  the  gall  bladder  and 
the  small  intestine. 

DILATATION  OF  THE  BILIARY  ORGANS. 

Dilatation  of  the  bile  ducts  is  always  a  consequence  of  their 
more  or  less  complete  occlusion.    Among  possible  causative  factors 


616     DISEASES  OF  THE  BILE  DUCTS  AND  GALL  BLADDER 

the  following  are  to  be  considered:  gallstones,  parasites,  chronic 
inflammation  with  obliteration  or  cicatricial  stenosis  of  the  ducts, 
congenital  occlusion  of  the  choledochus,  neoplasms,  aneurysms  of 
the  hepatic  artery,  fecal  stasis,  and  neoplasms  outside  the  liver. 

Hydrops  and  Empyema. — In  hydrops  the  arrested  bile  is  grad- 
ually absorbed,  being  replaced  by  a  serous  transudate  from  the 
bloodvessels.  A  pear-shaped  tumor  will  slowly  grow  and  occasion- 
ally attain  to  gigantic  size.  Empyema  of  the  gall  bladder  will 
follow  when  the  cystic  contents  undergo  infection  in  any  way. 

Symptoms. — Hydrops  of  the  gall  bladder  gives  rise  to  but  few 
subjective  manifestations— slight  pain  and  pressure  in  the  region 
of  the  gall  bladder.  The  course  is  chronic,  with  the  result  that 
the  condition  remains  unchanged  for  a  long  time,  causing  but 
slight  inconvenience  to  the  patient.  In  empyema,  fever  will 
develop,  with  chills  and  other  manifestations  of  sepsis. 

Treatment. — Physical  rest,  light  diet  and  mild  laxatives  may 
arrest  the  progress  of  hydrops.  Large  tumors  causing  much  dis- 
comfort, with  an  impending  rupture,  demand  surgical  interven- 
tion (cholecystotomy) ;  as  also  does  the  mere  suspicion  of  empyema. 

PARASITES  OF  THE  BILE  DUCTS. 

Echinococcus  cysts  are  among  the  parasitic  affections  most 
frequently  met  with  in  the  bile  ducts;  also  ascarides  and  Distoma 
hepaticum.  Ascarides  and  echinococci  may,  by  causing  occlusion 
of  the  bile  ducts,  give  rise  to  grave  consequences.  Ascarides 
invade  the  bile  ducts  from  the  duodenum.  The  changes  thereby 
produced  correspond  to  those  of  grave  suppurative  inflammation. 
A  cure  may  be  effected  if  the  ascarides  find  their  way  out  into  the 
intestine  through  the  choledochus  (see  page  801). 

Diagnosis. — The  diagnosis  can  only  be  made  with  great  reserve, 
it  being  necessary  to  demonstrate  the  presence  of  ascarides  aside 
from  the  symptoms  of  suppurative  cholangitis. 

Treatment. — The  treatment  has  then  to  be  directed  to  the  removal 
of  the  worms. 

GALLSTONES. 

Cholelithiasis. — Gallstones  are  concrements  which  form  in  the 
gall  bladder  and  bile  ducts.  They  are  of  most  varied  shape,  size 
and  composition,  and  may  be  divided  into  pure  cholesterol  stones, 
lamellated  cholesterol  stones,  pure  bilirubin  limestones,  bilirubin 
limestones  mixed  with  cholesterol,  and  stones  consisting  _  of  car- 
bonate of  lime.  The  number  of  stones  in  a  single  case  varies  from 
one  to  one  hundred  or  more.  They  are  found  in  the  liver,  in  the 
narrowest  bile  passages  (where  they  sometimes  appear  as  minute 
black  concrements),  in  the  hepatic  duct  or  its  branches,  in  the  gall 
bladder,  in  the  cystic  duct,  in  the  choledochus,  and  in  the  diver- 


GALLSTONES  617 

ticulum  of  Vater.  The  stones  found  in  the  cystic  and  common  bile 
ducts  usually  originate  in  the  gall  Madder.  Gallstones  are  also 
found  in  the  intestine,  which  they  may  enter  from  the  choledochus 
or  by  perforation  of  the  gall  bladder;  they^have  [been£found  in  the 
urinary  bladder  and  urethra  after  perforations.  The  size  of  the 
stones  varies;  some  are  no  larger  than  the  finest  sand,  others  may 
be  as  large  as  a  hen's  egg.  They  are  usually  round  or  oval.  When 
many  stones  lie  close  together,  they  will  flatten  by  contact  and 
become  polyhedral  (faceted).  Age  plays  a  considerable  part  in 
the  development  of  gallstones;  they  occur  at  any  age,  but  most 
frequently  between  the  ages  of  fifty  and  sixty.  The  proportion  of 
cases  in  the  male  as  compared  with  the  female  sex  is  as  2  to  3. 

As  to  the  origin  of  gallstones,  the  prevailing  modern  theory  is  as 
follows:  The  presence  of  bile  stasis  is  a  prerequisite,  whether  from 
mechanical  injuries  (tight  lacing,  pregnancy)  or  from  some  prece- 
dent affection  of  the  bile  ducts  or  liver.  The  arrested  bile  may 
exert  a  directly  injurious  influence  upon  the  epithelia  of  the  mucosa 
by  causing  a  kind  of  desquamative  catarrh  and  detaching  cellular 
detritus  containing  cholesterol,  around  which  the  gallstones  form, 
or  by  causing  the  formation  of  an  albuminous  and  calcareous 
secretion  of  the  mucosa,  under  the  influence  of  which  bilirubin  lime 
is  deposited  from  the  bile.  On  the  other  hand,  bile  stasis  may  favor 
the  access  of  microorganisms  from  the  intestine  or  the  blood,  and 
the  development  of  infectious  cholangitis,  the  affected  mucosa 
then  giving  rise  to  the  formation  of  gallstones  in  the  manner  just 
described.  As  a  matter  of  fact,  it  is  by  no  means  rare  for  the 
anamnesis  of  gallstone  patients  to  include  a  history  of  previous 
jaundice.  It  is  also  a  well-known  fact  that  gallstones  frequently 
occur  in  the  wTake  of  acute  infectious  diseases,  especially  influenza 
and  typhoid  fever.  According  to  another  theory,  the  biliary  salts 
which  keep  the  cholesterol  of  normal  bile  in  solution  are  decomposed 
by  the  bacteria,  precipitating  the  cholesterol.  Other  authors  main- 
tain that  genuine  stone  formation  can  only  occur  wiien  salts  and 
cholesterol  are  separated  from  the  bile  together  with  protein  sub- 
stances, protein  being  the  foundation  of  all  concrements  developed 
in  the  organism.  It  is  finally  to  be  considered  that  in  gallstone 
patients  hereditary  factors  often  play  a  role;  in  some  families  every 
member  suffers  from  this  disease.  It  is  also  a  noteworthy  fact  that 
biliary  and  renal  calculi  are  often  observed  in  one  and  the  same 
patient.  These  facts  admit  of  the  possibility  that  abnormal 
metabolic  processes  or  changed  consistency  of  the  blood  may  have 
to  be  taken  into  account  as  causative  factors.  Cholelithiasis  may 
result  from  an  excess  of  cholesterol  esters  in  the  digestive  tract  or 
in  the  blood  (cholesterolemia) ,  due  to  defective  metabolism  of 
ingested  lipoids,  or  to  an  excess  of  these  in  the  diet.  In  obstructive 
jaundice  the  cholesterol  content  of  the  blood  is  markedly  increased 
and  bears  a  definite  relationship  to  the  intensity  of  the  jaundice. 


618     DISEASES  OF  THE  BILE  DUCTS  AND  GALL  BLADDER 

In  conditions  associated  with  diseases  of  the  liver  the  cholesterol 
content  of  the  blood  is  usually  increased.  In  hematogenous  jaundice 
there  is  no  increase  of  blood  cholesterol. 

Symptoms. — A  great  many  individuals  harbor  gallstones  without 
ever  suffering  any  inconvenience  therefrom.  The  stones  remain 
at  rest  in  the  ducts  or  bladder.  Others  experience  slight  pain  or 
pressure  in  the  hepatic  region  and  slight  gastric  and  abdominal 
symptoms,  which,  however,  do  not  lead  to  colics  or  other  serious 
trouble.  The  great  majority  of  patients,  however,  suffer  from 
pronounced  gallstone  colic;  the  stones  wander  from  the  bile  ducts 
or  gall  bladder  through  the  choledochus  into  the  duodenum,  caus- 
ing more  or  less  severe  pain.  The  migration  of  stones  is  favored  by 
lifting  heavy  weights,  concussion  of  the  body,  psychic  irritation, 
or  partaking  of  cold  beverages.  The  paroxysms  may  run  a  light 
course,  or  lead  to  excruciating  pain  with  general  convulsions  and 
loss  of  consciousness.  They  vary  in  duration.  Occasionally  a 
paroxysm  will  last  for  several  days,  with  short  intervals.  The 
attack  usually  begins  a  few  hours  after  a  heavy  meal,  and  most 
often  in  the  evening  or  at  night.  The  region  of  the  gall  bladder 
becomes  very  painful  and  the  corresponding  part  of  the  abdominal 
wall  very  tense.  The  paroxysm  will  not  terminate  until  the  stone 
has  fallen  back  into  the  gall  bladder  or  entered  the  intestine.  A 
very  characteristic  sign  of  gallstone  paroxysms  is  almost  complete 
insensibility  to  pain  in  the  region  of  the  gall  bladder  immediately 
after  the  paroxysm  has  ceased.  If  the  paroxysm  has  been  unsuc- 
cessful, having  failed  to  remove  the  stone,  fresh  paroxysms  may 
occur  without  interruption  until  the  stone  or  stones  have  been 
evacuated.  Inflammatory  manifestations  and  fever  are  absent  in 
uncomplicated  paroxysms.  Should  fever  occur,  it  would  point  to 
simultaneous  inflammatory  processes  in  the  bile  duct.  When  a 
paroxysm  has  come  to  an  end,  patients  may  remain  unmolested 
for  a  time,  perhaps  for  many  years,  or  even  permanently.  In  other 
cases,  however,  the  concrements  will  lead  to  acute,  subacute  or 
chronic  irritative  and  inflammatory  conditions.  These  patients 
will  suffer  continually  from  more  or  less  pain,  pressure  and  tension 
in  the  hepatic  region,  and  are  often  driven  to  bed  as  a  consequence; 
the  acute  affection  has  developed  into  chronic  cholecystitis,  adhe- 
sions have  been  formed  with  the  surrounding  parts,  or  stones  have 
become  encapsulated  and  continually  irritate  the  surrounding  parts, 
causing  chronic  inflammation  and  ulceration.  In  the  event  of 
rupture  or  perforation  of  the  gall  bladder,  death  may  ensue. 

Diagnosis. — Roentgen-ray  examination  has  given  satisfactory 
results  in  50  per  cent,  of  the  cases  in  which  it  has  been  employed 
(Plate  XXI,  Fig.  2).  The  typical  gallstone  paroxysm  is  unmistak- 
able in  its  course  and  in  the  pain,  which  is  confined  to  the  right  side. 
Jaundice  need  not  be  present.  Gallstone  paroxysms  and  chronic 
gallstone  affections  may  be  mistaken  for  gastric  crises,  lead  colic, 


GALLSTONES  G19 

Intercostal  neuralgia,  appendicitis,  epigastric  hernia,  renal  or 
pancreatic  calculi,  acute  or  chronic  pancreatitis,  hepatic  abscess, 
inflammation  of  the  gall  bladder  from  other  causes,  abdominal 
pain,  gastric  or  duodenal  ulcer.  In  these  cases  it  is  not  easy 
to  make  a  safe  diagnosis.  In  many  cases  the  anamnesis  gives  a  cor- 
rect clue.  It  should  also  be  remembered  that  in  gallstone  affec- 
tions there  is  often  carcinoma  of  the  bile  ducts.  The  jaundice 
met  with  in  malignant  disease  is  distinguished  by  the  absence  of 
colic  and  pain,  gradual  onset  (without  remissions)  deepening  day 
by  day,  the  skin  finally  becoming  greenish-yellow.  Courvoisier 
pointed  out  many  years  ago  that  atrophy  of  the  gall  bladder  is 
the  rule  when  the  common  duct  is  occluded  from  within,  as  by  a 
gallstone.  When  a  gall  bladder  is  distended,  associated  with 
jaundice,  the  pressure  is  usually  outside  of  the  duct.  In  approxi- 
mately 85  per  cent,  of  cases  of  stone  in  the  common  duct  the  gall 
bladder  is  contracted.  Hypercholesterolemia  is  of  some  diag- 
nostic importance,  especially  when  surgical  measures  are  con- 
templated, though  it  must  not  be  forgotten  that  the  cholesterol 
content  of  the  blood  varies  widely  in  other  conditions,  such  as 
pregnancy,  gastric  or  duodenal  ulcer,  chronic  nephritis,  or  even 
simple  inanition. 

Xaunyn's  sign  for  cholecystitis  consists  of  deep  tenderness  when 
at  the  end  of  a  full  inspiration  the  examiner's  fingers  are  thrust 
upward  beneath  the  costal  arch  at  the  outer  limit  of  the  right 
epigastrium. 

Murphy's  sign  of  gall-bladder  disease  consists  in  the  inability 
of  the  patient  to  take  a  deep  inspiration  when  the  examiner's 
fingers  are  hooked  up  deep  beneath  the  right  costal  arch  below  the 
hepatic  margin. 

Examination  of  the  duodenal  contents  removed  with  the  duodenal 
tube  is  often  helpful  in  the  diagnosis.  Occasionally  small  stones  are 
thus  discovered.  The  finding  of  gall  sand  and  a  gritty  feeling 
experienced  by  the  examining  finger  are  very  suggestive.  Micro- 
scopically large  masses  of  crystals  and  bile  salts  are  frequently 
revealed  (see  page  109). 

Treatment. — Gallstone  colics  demand  rapid  help.  Unless  the 
attack  is  slight,  the  pain  should  be  relieved  by  anodynes  and  nar- 
cotics, the  best  being  a  liberal  subcutaneous  injection  of  rnorphin 
— 0.015-0.03  Gm.  (|  to  \  grain).  Atropin  may  be  combined  with 
the  rnorphin.  Opium,  pantopon  and  codein  do  not  have  the  same 
prompt  effect  as  rnorphin.  The  patient  is  brought  to  bed,  and 
hot  compresses  (poultices,  electric  pad,  hot-water  bottle)  are 
applied  to  the  hepatic  region.  A  prolonged  hot  bath  may  also  be 
given.  Olive  oil  will  often  mitigate  the  pain  (see  page  273). 
Vomiting  is  controlled  by  ice  chips  or  chloroform;  lavage  of  the 
stomach  with  hot  water  and  the  ingestion  of  large  quantities  of 
hot  liquids  have  a  favorable  effect.     In  collapse  the  usual  analeptics 


620     DISEASES  OF  THE  BILE  DUCTS  AND  GALL  BLADDER 

are  administered.  In  this  way  it  is  possible  to  help  patients  over 
a  serious  attack  with  comparative  ease.  The  patient  remains  in 
bed  until  the  pain  and  pressure  in  the  hepatic  region  have  dis- 
appeared. During  the  following  few  days  it  will  be  opportune  to 
prescribe  mild  laxatives.  When  there  are  no  further  signs  of 
paroxysms  and  no  other  symptoms,  patients  may  resume  their 
occupation. 

If  gallstone  paroxysms  have  been  definitely  demonstrated,  if 
the  paroxysms  are  of  frequent  recurrence  at  regular  or  irregular 
intervals,  or  if  there  are  permanent  symptoms  of  chronic  inflam- 
matory conditions  in  the  biliary  system,  the  general  treatment  of 
gallstone  affections  has  to  be  instituted.  The  object  of  this  treat- 
ment is  not  the  removal  of  the  gallstones,  for  there  are  no  medicinal 
means  at  our  disposal  to  accomplish  such  a  purpose.  The  princi- 
pal object,  rather,  is  to  establish  a  stage  of  latency — rest  in  the 
entire  system  of  bile  channels.  If  this  can  be  accomplished,  the 
inflammatory  changes  in  the  gall  bladder  and  bile  ducts,  which 
are  present  in  the  majoiity  of  all  cases,  may  undergo  a  complete 
cure.  The  first  rank  in  the  treatment  of  gallstone  disease  is  held 
by  the  Carlsbad  mineral  waters.  These  are  best  taken  at  the 
springs,  but,  other  conditions  being  favorable,  may  also  be  taken 
at  home.  All  cases  of  cholelithiasis  are  suitable  for  this  treatment, 
but  preferably  those  which  have  exhibited  symptoms  for  a  short 
time  only.  In  these  cases  the  Carlsbad  cure  may  also  by  way  of 
prophylaxis  prevent  further  concrement-formation.  The  favor- 
able action  of  the  Carlsbad  waters  is  partly  explained  by  their 
anticatarrhal  effect.  It  may  further  be  assumed  that  these  hot 
mineral  waters  improve  the  circulatory  conditions  in  the  hepatic 
region,  thereby  increasing  the  fluidity  of  the  bile  and  inhibiting 
stone-formation,  and  that  the  more  fluid  bile  will  carry  away  small 
concrements.  All  the  saline  laxatives  act  in  a  similar  manner 
and  are  of  great  value  (see  page  284);  it  is  said  that  they  cause 
cholesterolemia  to  disappear,  should  such  exist.  If  the  gastric 
motility  is  normal  the  Carlsbad  treatment  can  be  given  as  described 
on  page  611.  While  taking  the  cure  it  is  important  that  the  patient 
rest  reclining,  to  protect  the  body  from  unnecessary  concussion. 
Before  and  after  dinner  one  and  one-half  to  two  hours  should  be 
spent  in  the  dorsal  decubitus,  during  which  time  hot  poultices  or 
compresses  may  be  applied  to  the  hepatic  region.  The  rest  cure 
should  be  continued  to  some  extent  for  several  months  after  the 
mineral-water  treatment  has  been  discontinued — careless  move- 
ments, long  walks,  etc.,  being  avoided.  The  transition  to  a  more 
strenuous  life  should  be  gradual. 

While  taking  the  treatment  the  diet  should  be  absolutely  bland. 
All  food  should  be  carefully  comminuted,  and  the  meals  should 
be  small  and  frequent.  A  diet  rich  in  carbohydrates  is  generally  to 
be  commended.     As  inundation  of  the  liver  with  nitrogenous  sub- 


GALLSTONES  621 

stances  is  to  be  avoided,  the  quantity  of  meat  should  be  restricted. 
Poods  rich  in  fat,  as  eggs,  butter,  cream  and  fish,  tend  to  increase 
the  eholesterolemia  and  should  be  rigidly  excluded  in  cases  show- 
ing an  excessive  amount  of  cholesterol  in  the  blood.  Fresh  bread, 
bakers'  wares  prepared  with  yeast,  raw  fruit,  and  coarse  vege- 
tables are  disallowed.  Alcohol  is  allowed  in  the  form  of  a  light 
white  wine,  but  not  if  there  is  hyperacidity.  Cold  foods  and 
beverages,  especially  those  cooled  on  ice,  are  to  be  scrupulously 
avoided. 

Medication. — Cholagogues  and  antiseptics:  Podophyllin,  0.03  to 
0.05  Gm.  (|  to  1  grain)  in  pills;  calomel;  belladonna;  salicylic 
acid;  sodium  salicylate,  0.5  to  1  Gm.  (7|  to  15  grains);  and  hexa- 
methylenamin,  0.5  Gm.  (7|  grains)  several  times  daily.  There  are 
many  proprietary  combinations,  such  as:  probilin  pills  (consisting 
of  salicylic  acid,  sodium  oleate,  menthol  and  phenolphthalein) ; 
eunatrol,  containing  sodium  oleate;  and  agobilin,  containing 
cholic  acid,  strontium  and  phenolphthalein.  Chologen,  as  recom- 
mended by  Glaser,  consists  of  calomel,  podophyllin,  camphor, 
caraway  and  aromatics,  and  has  given  good  results  in  some  cases. 
It  is  supposed  not  only  to  increase  the  quantity  of  bile,  but  to 
increase  the  proportion  of  the  normal  constituent  which  is  said  to 
be  a  gallstone  solvent.  It  is  given  in  tablet  form  before  each  meal, 
the  dose  being  increased  or  decreased  according  to  the  movement 
of  the  bowels.  According  to  recent  clinical  experience,  during  the 
first  ten  days  one  or  two  tablets  of  No.  1  are  taken  before  the  morning 
and  midday  meals.  During  the  next  forty  days  one  or  two  tablets 
of  No.  1  are  taken  before  the  morning  and  midday  meals  and  two 
tablets  of  No.  2  are  taken  before  the  evening  meal.  During  the 
next  ten  days  one  tablet  of  No.  3  is  taken  before  the  morning,  mid- 
day and  evening  meals.  If  an  attack  of  gallstone  colic  is  threatened, 
three  tablets  of  No.  2  should  be  taken  at  once.  When  the  inflam- 
mation in  the  bile  ducts  or  gall  bladder  is  very  severe,  with  fever  and 
chills,  the  systematic  administration  of  calomel,  0.1  Gm.  (1|  grains) 
three  times  a  day,  kept  up  for  at  least  four  weeks,  may  save  the 
patient  an  operation.  Generally,  the  course  of  cholelithiasis  seems 
to  be  benefited  by  the  use  of  mild  laxatives  (see  Chapter  XIV)  from 
the  very  beginning  of  the  treatment,  since  easy  stools  provoke  secre- 
tion of  bile.  Partaking  of  frequent,  easily  digestible  meals  has  a 
distinct  cholagogue  effect.  In  hyperacidity  the  administration  of 
the  alkalis  is  beneficial.  For  the  relief  of  the  colic,  papaverin  or 
benzyl  benzoate  can  be  employed  (see  page  276) . 

Non-surgical  Biliary  Drainage. — The  biliary  apparatus  can  be 
drained  by  the  use  of  the  duodenal  tube  (see  Chapter  III) .  Meltzer 
found  that  a  25-per-cent.  solution  of  magnesium  sulphate  in  the 
duodenum  produced  complete  relaxation  of  the  intestinal  wall.  It 
is  thus  possible,  by  the  use  of  magnesium  sulphate  introduced 
directly  into  the  duodenum,  to  relax  the  sphincter  of  the^common 


622     DISEASES  OF  THE  BILE  DUCTS  AND  GALL  BLADDER 

duct  and  permit  the  ejection  of  bile  and  even  the  removal  of  a  cal- 
culus of  moderate  size  wedged  in  the  duct  in  front  of  the  papilla  of 
Vater. 

Surgical  Treatment. — Cases  of  gallstone  colic  which  occur  at 
certain  intervals  but  pass  without  unduly  interfering  with  the 
patient's  occupation  do  not  require  an  operation.  Exaggerated 
frequency  of  the  attacks  and  considerable  interference  with  work 
may  render  an  operation  desirable.  The  prognosis  of  these  opera- 
tions (cholecystotomy,  cholecystectomy)  is  generally  good;  the 
mortality  is  3  per  cent,  in  the  absence  of  inflammation,  5  to  10 
per  cent,  when  there  is  suppurative  inflammation.  Cholelithiasis 
associated  with  cholemia  and  inflammation  is  an  absolute  indica- 
tion for  operation.  Occlusion  of  the  choledochus  by  stones  demands 
operation,  unless  the  concrements  are  evacuated  at  an  early  stage. 
Fever,  chills  and  septic  manifestations  demand  prompt  surgical 
intervention,  although  a  delay  of  a  few  weeks  is  permissible  when  the 
course  is  chronic.  It  should  be  remembered,  however,  that  jaundice 
involves  danger  and  that  chronic  cholangitis  may  lead  to  abscess 
of  the  liver.  Perforation  of  pus  and  stones  into  the  peritoneal 
cavity  is  an  urgent  indication  for  operation.  We  now  know  that 
various  diseases  are  intimately  related  to  one  another.  The  gall 
bladder  and  appendix  have  been  found  involved  at  operation  for 
ulcer  of  the  stomach  and  duodenum.  It  is  said  that  in  30  per  cent, 
of  all  diseases  of  the  gall  bladder  there  is  an  infected  appendix. 
Surgeons  should  always  examine  the  appendix  when  they  operate 
on  the  gall  bladder. 


CHAPTER  XXXIII. 

DISEASES  OF  THE  PANCREAS. 

Pancreatitis;  Aciiylia;  Hemorrhage;  Necrosis;  Cysts; 
Tumors;  Calculi. 

INFLAMMATION  OF  THE  PANCREAS. 

Many  acute  and  chronic  affections  of  the  pancreas  require 
surgical  treatment.  Internal  treatment  plays  rather  an  adjuvant 
but  by  no  means  unimportant  role,  especially  in  regard  to  diet, 
as  will  be  explained.  Very  few  pancreatic  affections  are  directly 
benefited  by  medicinal  treatment;  these  include  pancreatic  fistulse, 
functional  disturbances  of  the  pancreatic  secretion  secondary  to 
achylia  gastrica,  cholelithiasis  or  cholecystitis,  or  primary  (achylia 
pancreatica)  and  chronic  pancreatitis — notably  the  last  named. 
Chronic  pancreatitis  will  be  dealt  with  first,  because  its  clinical 
manifestations,  especially  in  regard  to  digestion,  are  more  or  less 
met  with  in  other  chronic  pancreatic  affections  (tumors,  calculi), 
and  because  the  indications  for  internal  medication  can  be  clearly 
deduced  from  its  clinical  course. 

Chronic  Pancreatitis. — This  affection  is  by  no  means  as  rare  as 
is  often  supposed,  and,  with  our  modern  knowledge,  can  in  most 
cases  be  correctly  diagnosticated,  although  the  anamnesis  does  not 
furnish  any  typical  data.  It  usually  begins  with  an  ill-defined 
sensation  of  pressure  and  fulness  in  the  abdomen,  intermittent 
colicky  pains  and  pains  in  the  back,  and  irregularity  of  stool.  These 
symptoms  may  persist  for  years,  but  are  often  of  short  duration. 
Increasing  disturbances  of  digestion  and  occasional  colicky  pains 
drive  the  patient  to  his  physician  for  aid.  The  symptoms  consist 
of  anorexia,  gastric  pains,  and  irregular  stools  alternately  massy 
and  abnormally  thin.  These  patients  are  often  subjected  to  all 
manner  of  treatment  intended  to  relieve  the  gastric  complaints 
and  the  inflammation  of  the  large  and  small  intestine,  or  they  are 
sent  to  spas,  with  the  result  that  their  condition  is  aggravated  and 
the  digestive  symptoms  increase.  Not  until  an  exact  fecal  exami- 
nation has  been  made  is  it  possible  to  diagnose  the  condition,  and 
the  method  is  a  rather  simple  one  (seepage  125).  Deterioration 
in  quality  or  quantity  of  the  pancreatic  trypsin,  steapsin  or  dias- 
tase is  revealed  by  the  presence  of  partially  digested  food  remnants 
in  the  feces  while  the  patient  is  taking  a  test  diet.  The  digestion 
is  more  or  less  seriously  impaired,  according  to  whether  the  entire 


624  DISEASES  OF  THE  PANCREAS 

pancreas  or  only  part  of  it  is  affected.  It  can  be  understood  that 
in  chronic  pancreatitis  the  digestive  disturbances  are  usually  quite 
pronounced,  the  entire  organ  being  affected,  while  tumors  of  the 
pancreas,  for  instance,  often  cause  but  slight  irregularities,  since 
they  destroy  only  part  of  the  gland.  Even  occlusion  of  the  pan- 
creatic excretory  ducts  often  causes  but  slight  disturbance  so  long 
as  vicarious  pancreatic  function  by  internal  secretion  occurs,  to 
say  nothing  of  the  fact  that  the  bile  and  intestinal  juice  may  in 
part  perform  the  function  of  the  pancreas. 

Etiology. — Etiologically,  chronic  alcoholism,  syphilis  and  arterio- 
sclerosis have  to  be  considered.  Chronic  lead  and  mercury  intoxi- 
cations no  doubt  also  play  a  role  in  the  development  of  chronic 
pancreatitis.  There  is  no  doubt  either  that  chronic  pancreatitis 
may  also  result  from  the  spreading  of  inflammatory  processes 
from  neighboring  organs  to  the  pancreas,  as  in  cholecystitis,  chole- 
lithiasis, and  gastric  and  duodenal  ulcer.  Occlusion  of  Wirsung's 
duct  by  calculi  may  likewise  lead  to  chronic  pancreatitis.  Chronic 
gastritis  or  achylia  may  also  cause  functional  disturbances  of  the 
pancreatic  secretion,  it  being  a  well-known  fact  that  the  hydro- 
chloric acid  of  the  stomach  is  a  powerful  stimulant  to  pancreatic 
secretion.  These  functional  derangements  may  finally  eventuate 
in  chronic  inflammation  of  the  pancreas. 

Pathology. — From  an  anatomic-pathologic  point  of  view  chronic 
pancreatitis  is  a  cirrhosis  of  the  pancreas  with  interlobular  or  intra- 
lobular connective-tissue  proliferation,  degeneration  of  the  islands 
of  Langerhans,  and  atrophy  of  the  parenchyma,  the  pancreas 
inclining  to  contraction  and  not  to  enlargement. 

Diagnosis.- — The  test-diet  stool  method  of  diagnosis  (see  Chapter 
IV)  discloses  the  following  digestive  disorders  in  chronic  pancrea- 
titis : 

Disturbance  of  Protein  Digestion. — In  the  finely  rubbed-up  feces 
one  can  often  detect  without  the  microscope  remnants  of  meat, 
which  are  not  only  characteristic  but  of  diagnostic  value  on  account 
of  the  fact  that  the  nuclei  are  preserved.  Schmidt  has  shown 
that  the  cellular  nuclei  are  not  digested  by  the  gastric  juice,  but 
only  by  the  pancreatic;  it  is  upon  this  division  of  proteolytic 
function  that  his  well-known  nucleus  test,  the  demonstration  of 
undigested  cellular  nuclei  in  meat  particles  regained  from  the  feces, 
is  based  (see  page  126).  Kashiwado  has  simplified  this  method  by 
repeatedly  administering  in  the  middle  of  the  day  two  colored  con- 
nective-tissue capsules  (especially  prepared  by  Merck),  which  are 
later  searched  for  in  the  stools.  Should  they  be  distinctly  demon- 
strable, defective  pancreatic  function  is  inferred.  There  are,  how- 
ever, pancreatic  disorders  in  which  the  meat  digestion  is  impaired 
while  the  nucleus  digestion  is  perfect.  If  the  meat  remnants  can  be 
detected  macroscopically,  the  microscope  will  in  these  cases  reveal 
large  numbers  of  large,  angular,  muscular  fragments,  with  their 


TNFLAMMATlOh   OF  THE  PANCREAS  625 

transverse  striatic*]  well  preserved,  which,  upon  dose  inspection, 
clearly  give  the  impression  of  being  poorly  digested. 

Disturbance  of  Fat  Digestion. — In  defective  steapsin  secretion  the 
stool  of  the  test  diet  contains  very  large  quantities  of  fat,  clearly 
visible  as  an  abundant  fatty  layer  on  the  feces  finely  rubbed  up 
with  water,  the  entire  stool  looking  as  if  a  fatty  layer  had  been 
poured  over  it  which  had  congealed  after  defecation.  The  influx 
of  bile  not  being  disturbed  in  pancreatitis,  the  stool  retains  its 
brown  color,  except  that  it  may  at  times  be  lighter  in  hue  than 
normal;  whereas  in  jaundice  it  is  gray  or  white  owing  to  inter- 
ference with  the  flow  of  the  bile  pigment.  When  the  feces  are 
covered  with  a  fat  layer,  the  fat  is  usually  neutral,  though  it  may 
contain  free  higher  fatty  acids.  This  form  of  loss  of  fat,  though 
it  points  to  pancreatic  involvement  alone,  may  possibly  be  due  to 
other  causes.  Microscopic  examination  reveals  a  moderate  quan- 
tity of  fat  in  the  shape  of  fatty  acid  needles  and  soap  crystals, 
and  in  many  instances  drops  either  neutral  or  acid  (see  page  120). 
According  to  Lohrisch  these  fat  drops  can  be  differentiated  by  a 
concentrated  solution  of  Nile  blue  sulphate,  which  stains  neutral 
fat  red,  fatty  acid  blue. 

Disturbance  of  Starch  Digestion. — When  a  solution  of  potassium 
biniodid  is  added  to  the  feces,  more  or  less  numerous  undigested 
starch  grains  are  often  discovered.  Undigested  starch  remnants 
may  also  be  demonstrated  in  the  fermentative  processes  by  apply- 
ing the  incubator  test  (see  page  121) .  If  the  digestive  disturbance,  as 
described,  has  persisted  for  a  long  time  or  is  of  a  very  severe  nature, 
it  will  sooner  or  later  lead  to  catarrh  of  the  small  and  large  intestine, 
demonstrable  in  the  fecal  examination  by  the  presence  of  mucus 
or  putrefactive  processes.  Should  there  be  simultaneous  achylic 
or  subacid  gastric  conditions,  the  feces  will  contain  undigested 
remnants  of  connective  tissue. 

If,  in  addition  to  these  digestive  disorders,  the  anamnesis  and 
other  clinical  findings  (pain  on  pressure  in  the  pancreatic  region, 
colicky  pains,  emaciation)  are  taken  into  consideration,  there 
should  be  no  difficulty  in  arriving  at  a  diagnosis  of  pancreatic 
affection.  Simultaneous  diabetes  would,  of  course,  strengthen  the 
diagnosis  still  further.  Demonstration  of  trypsin  and  diastase  (see 
pages  125-126)  in  the  feces  may  in  some  cases  be  omitted,  for 
should  the  tests  already  described  prove  negative  the  digestive  dis- 
turbances are  often  quite  characteristic  enough  to  clear  up  the  diag- 
nosis. It  is,  of  course,  not  always  possible  to  diagnose  at  once  chronic 
pancreatitis  to  the  exclusion  of  other  affections  of  the  pancreas, 
further  observations  being  frequently  necessary  for  this  purpose. 
Chronic  pancreatitis  should  be  particularly  suspected  when  the 
disease  remains  stationary  or  undergoes  temporary  improvement. 

Since  the  contents  of  the  duodenum  can  be  easily  removed  by 
the  duodenal  tube  (see  page  98),  the  condition  of  the  pancreas  can  in 
40 


626  DISEASES  OF  THE  PANCREAS 

some  measure  be  estimated  by  this  means.  The  presence  of  bile 
and  pancreatic  secretion  in  the  duodenum  permits  gauging  the 
pancreatic  function.  The  presence  of  all  three  ferments  in  suffi- 
cient quantity  indicates  normal  activity  of  the  pancreas.  If  one 
of  the  ferments  is  constantly  absent,  this  usually  indicates  chronic 
pancreatitis  (Einhorn).  A  tumor  of  the  pancreas  may  exist  not- 
withstanding the  presence  of  all  three  ferments. 

Oil  Test  Breakfast. — It  has  been  found  that  oil  introduced  into 
the  stomach  usually  induces  regurgitation  of  pancreatic  juice,  bile 
and  succus  entericus  into  the  stomach.  Next  to  the  removal  of 
the  intestinal  juices  by  the  duodenal  tube  and  the  duodenal  bucket, 
for  demonstrating  the  presence  or  absence  of  the  pancreatic  fer- 
ments, the  oil  test  breakfast  is  best  for  analytic  purposes.  This  test 
depends  upon  the  splitting  of  a  neutral  oil  by  the  pancreatic  ferment 
into  fatty  acid  and  glycerin.  The  fatty  acids  are  recognized  by 
their  green  color,  due  to  the  formation  of  copper  salts.  Palmin  is 
the  oil  that  should  be  used.  The  patient  is  to  take  an  oil  test  break- 
fast on  an  empty  stomach — 30  grams  (one  ounce)  of  rice  starch 
dissolved  in  J  liter  (eight  ounces)  of  warm  water  (with  a  little  salt 
if  desired),  to  which  is  added  75  Cc.  (2|  ounces)  of  warm  palmin 
oil;  mix  thoroughly.  The  whole  quantity  is  taken  at  once.  In 
two  or  two  and  a  half  hours  the  stomach  contents  should  be  removed 
through  a  tube  and  tested  immediately.  In  order  to  secuie  the 
reaction  two  solutions  are  necessary.  The  first  consists  of  petro- 
leum ether  ninety  parts  and  distilled  water  ten  parts.  The  second 
consists  of  a  3-per-cent.  solution  of  copper  acetate  in  distilled  water. 
Equal  parts  of  the  first  solution  and  the  stomach  contents  are  placed 
in  a  test  tube,  thoroughly  shaken,  and  allowed  to  stand;  then  the 
supernatant  ether  is  poured  into  another  test  tube,  to  which  an 
equal  quantity  of  the  second  solution  is  added,  and  the  tube  shaken. 
If  there  are  any  fatty  acids  present,  they  unite  with  the  copper, 
forming  a  salt  with  an  intense  green  color,  easily  discernible  to  the 
eye.  If  there  is  no  pancreatic  juice  present,  the  solution  remains 
clear,  showing  that  there  has  been  no  splitting  of  the  palmin. 

Loewi's  Pupillary  Reaction.- — We  owe  to  Loewi  (1908)  the  dis- 
covery that  epinephrin  will  dilate  the  pupil  in  animals  from  which 
the  pancreas  has  been  removed.  From  this  fact  it  has  been  inferred 
that  pupillary  reaction  to  epinephrin  indicates  insufficiency  of  pan- 
creatic secretion — Graves'  disease  being  excluded.  The  pupillary 
test  is  made  simply  by  instilling  a  few  drops  of  epinephrin  solution, 
1 :  1000,  in  the  conjunctival  sac,  and  noting  the  effect. 

Cammidge  Reaction. — In  his  recent  investigations  on  the  urine  of 
patients  suffering  from  pancreatic  disease,  Cammidge  has  found 
that  the  appearance  of  sugar  in  the  urine  in  diseases  of  the  pan- 
creas is  preceded  by  a  marked  rise  in  the  excretion  of  dextrin,  which 
falls  when  glycosuria  is  established.  He  has  elaborated  a  test 
known  as  the  Cammidge  reaction.    The  reaction  depends  upon  the 


INFLAMMATION  OF  THE  PANCREAS  621 

formation  of  an  osazone  by  the  pentose  (xylose)  >plit  off  from  the 
dextrin  by  hydrolyzing  with  hydrochloric  acid;  and  in  the  quan- 
titative method  the  "  iodin  coefficient"  of  the  urine  is  a  measure 
of  its  content  of  dextrin.  The  determinations  of  the  "iodin 
coefficient"  are  not  only  useful  in  the  diagnosis  of  diseases  of  the 
pancreas,  hut  also  afford  a  means  of  detecting  the  preglycosuric 
stage  of  diabetes. 

Pain  and  tenderness  on  pressure  in  the  vicinity  of  the  twelfth 
dorsal  and  first  and  second  lumbar  vertebra?  is  significant  of  disease 
of  the  pancreas. 

The  presence  of  all  the  ferments  in  sufficient  quantity  indicates 
normal  pancreatic  activity.  This  can  be  easily  ascertained  by  an 
examination  of  the  duodenal  contents  (see  page  103). 

Prognosis. — The  prognosis  of  chronic  pancreatitis  is  uncertain, 
but  not  entirely  unfavorable,  since,  with  a  correct  mode  of  living, 
the  affection  may  either  come  to  a  standstill  or  show  improvement. 

Treatment. — The  preceding  explanations  indicate  the  logical 
internal  treatment.  The  first  point  is  to  modify  or  remove  the 
cause.  Biliary  calculi,  cholecystitis,  gastric  or  duodenal  ulcer, 
if  present,  should  be  most  thoroughly  treated,  because  a  cure  of 
these  conditions  affords  substantial  hope  of  arresting  the  pancreatic 
affection.  A  stay  at  Saratoga,  Carlsbad  or  Marienbad  has  often 
a  favorable  effect.  Prolonged  rest  in  bed,  in  conjunction  with  a 
carefully  regulated  diet,  may  likewise  exert  a  favorable  influence 
upon  the  pancreatic  affection.  Any  affection  of  the  stomach,  in 
particular  achylia  or  subacidity,  atony  or  chronic  catarrhal  affec- 
tion, should  be  carefully  treated,  especially  when,  it  has  led  to 
gastrogenic  diarrhea  (see  page  673).  Irrigation  of  the  stomach  is 
often  very  useful  in  atony  of  that  organ.  In  subacid  and  achylic  con- 
ditions, hydrochloric  acid  and  pepsin  should  be  administered  in 
abundant  quantities  to  relieve  the  gastrogenic  diarrhea  (see  page 
258). 

Small  quantities  of  hydrochloric  acid  may  also  be  taken  before 
meals  in  order  to  incite  pancreatic  secretion. 

Regulation  of  the  diet  is  of  the  greatest  importance.  Generally 
speaking,  it  is  easy  to  prescribe  the  necessary  diet,  based  upon  the 
findings  of  the  fecal  examinations.  It  should  fulfil  the  following 
requirements: 

1.  Limitation  of  Fat. — Butter,  cream,  oil,  and  meat  fat  should 
be  given  as  sparingly  as  possible.  Milk  is  allowable  in  small 
quantities  only. 

2.  Limitatvm  of  Protein. — Meat  and  eggs  should  be  limited  to 
small  quantities,  the  meats  being  thoroughly  chopped  and  all  egg 
dishes  prepared  in  the  most  readily  digestible  form.  Smoked 
and  pickled  meats  are  prohibited.  Rare  meat  is  permissible  only 
in  the  shape  of  carefully  scraped  beef  or  tender  ham.  Vegetable 
proteins  (roborat,  mutase,  etc.)  may  be  administered  as  substitutes 


628  DISEASES  OF  THE  PANCREAS 

for  animal  food.  Gelatins  supply  but  little  putrefactive  material, 
and  are  therefore  valuable.  Erepton,  consisting  of  meat  artificially 
digested  by  the  action  of  trypsin  and  erepsin,  and  having  a  nitrog- 
enous content  of  about  12  per  cent.,  is  recommended. 

3.  Carbohydrates  may  be  given  in  abundant  quantities,  preferably 
in  the  shape  of  fine  farinaceous  food,  or  soup  prepared  with  fine 
soup  flour.  White  bread,  biscuits,  cakes,  rice,  hominy,  sago,  dry 
vegetables,  mashed  potatoes,  etc.,  are,  of  course,  likewise  included 
in  the  diet.  Individualizing  is  a  necessary  requisite,  and  the  menu 
should  not  be  too  monotonous.  With  due  regard  to  the  severity 
of  the  digestive  disturbance,  green  vegetable  puree  (spinach,  etc.), 
apple  sauce,  and  similar  dishes  may  be  allowed.  If  diabetes,  at  any 
rate  severe  diabetes,  is  present,  saccharin  should  be  substituted 
for  sugar.  Beverages  containing  carbon  dioxid,  such  as  beer,  are 
best  avoided,  but  wine  is  allowable  in  small  quantities. 

To  assist  the  digestion  of  fat  as  well  as  of  meat,  pancreatin  and 
pankreon  are  administered  with  advantage  (see  page  262).  Pan- 
creatin is  effective  in  a  neutral  or  weakly  alkaline  solution  only,  and 
is  therefore  particularly  useful  in  cases  of  achylia  gastrica.  In 
normal  gastric  conditions  it  should  be  administered  with  bicarbonate 
of  sodium,  a  quarter  of  an  hour  after  meals.  Pancreatin  preparations 
in  most  cases  very  materially  aid  in  the  splitting  up  and  absorption 
of  fat  as  well  as  the  digestion  of  starches.  They  may  be  continued 
for  a  long  time.  The  carbohydrate  digestion  may  also  be  assisted 
by  vegetable  diastase — for  example,  taka-diastase,  administered 
during  meals  in  doses  of  0.2  to  0.5  Gm.  (3  to  1\  grains). 

Slow  eating,  regular  distribution  of  the  meals  over  the  day,  and 
rest  after  meals  are  of  course  necessary.  Warm  compresses,  dry 
or  moist,  applied  to  the  abdomen  after  meals,  usually  produce  a 
comfortable  sensation.  Light  cases  of  chronic  pancreatitis  do  not 
contra-indicate  careful  electric  treatment,  abdominal  massage,  or 
baths  and  hydrotherapeutic  measures  in  a  mild  form. 

The  above  exhausts  the  internal  therapeutic  possibilities  in 
chronic  pancreatitis,  according  to  our  present  knowledge.  Func- 
tional disturbances  of  the  pancreatic  secretion  (achylia  pancreatica) 
are,  of  course,  to  be  treated  in  the  same  way. 

Surgical  Treatment. — Surgery  is  generally  powerless  in  chronic 
pancreatitis.  It  might  possibly  come  in  for  consideration  in  chronic 
peripancreatitic  processes  for  the  resection  of  adhesions,  splitting  the 
pancreatic  capsule,  etc.,  but  it  is  very  difficult  to  diagnose  peri- 
pancreatitis with  that  degree  of  certainty  which  is  necessary  in 
advising  operation. 

Acute  Pancreatitis. — Acute  inflammation  of  the  pancreas  is 
nearly  always  due  to  bacteria,  principally  the  Bacterium  coli  com- 
munis, invading  the  pancreatic  duct  from  the  intestine.  There 
may  also  be  hematogenous  bacterial  invasion  of  the  pancreas, 
notably  in  the  course  of  infectious  diseases,  as  in  pyemia.    Strepto- 


INTERNAL   TREATMENT  029 

cocci,  staphylococci,  typhoid  bacilli  and  Frankel's  pneumococci  bave 
all  been  found  in  these  infections.  Acute  pancreatitis  also  appears 
as  a  sequel  to  affections  of  the  liver  and  bile  ducts,  gastric  and  duo- 
denal ulcers,  and  carcinoma  of  the  stomach,  and  occasionally  in 
association  with  pancreatic  calculi.  It  is  more  often  observed  in  men 
than  in  women.  The  inflamed  pancreas  is  usually  enlarged  and  very 
plethoric.  The  inflammation,  when  very  intense,  may  lead  to 
hemorrhages  into  the  pancreas  (pancreatitis  hemorrhagica).  Sup- 
puration of  the  pancreas  may  also  occasionally  occur  (pancreatic 
abscess).  Acute  pancreatitis  usually  begins  with  violent  pains 
in  the  upper  abdominal  region,  accompanied  by  vomiting  and 
collapse,  and  often  by  symptoms  of  ileus  and  peritonitis.  The 
body  temperature  is  often  elevated.  Fitz's  syndrome,  suggesting 
acute  pancreatitis,  consists  of  severe  epigastric  pain,  vomiting  and 
collapse,  appearing  suddenly  and  followed  within  twenty-four  hours 
by  a  circumscribed  swelling  in  the  epigastrium,  with  tympanites.  A 
percussion  sign  of  acute  pancreatitis  "so  absolute,"  according  to  its 
discoverer,  "that  it  can  be  felt,"  is  described  by  Todd,  of  Adelaide, 
Australia,  as  "dulness  in  both  flanks,  unaltered  by  any  change  of 
posture,"  and  attributable  to  a  collection  of  blood  in  both  kidney 
pelves.  A  general  or  local  cyanosis  is  a  common  symptom.  The 
test-diet  stool  is  characteristic.  The  prognosis  is  very  serious,  the 
affection,  as  a  rule,  running  a  fatal  course. 

Treatment. — The  treatment  is  surgical,  consisting  in  laparotomy, 
removal  of  the  pathologic  glandular  tissue,  and  evacuation  of  the 
pus.  Professor  Gosset,  of  Paris,  believes  the  gall  bladder  should 
be  drained  in  every  case. 

Internal  Treatment  in  Other  Affections  of  the  Pancreas. — Nothing 
is  available  here  but  regulation  of  the  diet.  This,  however,  is  by 
no  means  an  unimportant  point,  and  may  be  attended  with  very 
good  results  in  some  of  these  affections.  Dietetic  treatment  is 
based  upon  experimental  physiology.  Pawlow's  experiments  upon 
dogs  and  the  observations  of  Wohlgemuth  upon  pancreatic  fistula? 
in  man  have  shown  that  the  pancreatic  secretion,  aside  from  psychic 
influences,  can  be  characteristically  affected  by  various  articles 
of  food.  It  has  been  shown  that  carbohydrates  (potatoes,  bread, 
farinaceous  food,  etc.)  incite  pancreatic  secretion  to  a  considerable 
extent.  Protein  food  is  much  less  effective  in  this  respect,  while 
pancreatic  secretion  is  almost  completely  arrested  after  the  inges- 
tion of  fat.  It  is  also  a  well-known  fact,  as  already  stated,  that 
hydrochloric  acid  stimulates  pancreatic  secretion,  while  bicarbo- 
nate of  sodium  distinctly  inhibits  it.  These  effects  upon  pancreatic 
function  are  not  all  direct;  we  know  that  proteins  and  carbo- 
hydrates do  not  of  themselves  directly  influence  pancreatic  secre- 
tion; on  the  other  hand,  fats  have  a  moderately  stimulating  effect. 
These  various  foods  influence  the  pancreas  through  the  stomach, 
by  their  effect  upon  the  secretion  of  free  hydrochloric  acid.    Con- 


630  DISEASES  OF  THE  PANCREAS 

sidering,  therefore,  that  carbohydrates,  while  they  incite  hydro- 
chloric acid  production,  do  not  combine  with  this  acid  as  proteins 
do,  they  stimulate  indirectly,  for  the  same  reason,  the  pancreatic 
secretion.  Internal  medicine  profits  by  this  experience  by  either 
limiting  or  increasing  the  pancreatic  secretion,  according  to  require- 
ments, by  regulation  of  the  diet.  In  acute  affections  of  the  pan- 
creas, as  for  instance  after  injuries  or  trauma,  when  abundant 
pancreatic  secretion  would  involve  danger  to  life,  in  fact  in  all  cases 
where  protective  treatment  of  the  pancreas  is  indicated,  carbo- 
hydrates should  be  omitted  and  bicarbonate  of  sodium  prescribed. 
The  reverse  holds  true  in  cases. where  increased  secretion  is  desir- 
able, for  instance  in  achylia  pancreatica  or  in  constriction  or  occlu- 
sion of  the  excretory  ducts  due  to  calculi  or  other  causes.  In  these 
cases  a  diet  rich  in  carbohydrates  is  desirable  in  the  hope  of  over- 
coming the  obstruction  by  increased  secretion.  This  purpose  is 
also  effected  by  the  protracted  use  of  pilocarpin,  one  of  the  con- 
stituents of  jaborandi — pilocarpin  hydrochlorid  0.005  to  0.02  Gm. 
(tV  to  |  grain)  hypodermically  daily.  Light  massage  and  gym- 
nastic exercises  may  also  conduce  to  the  expulsion  of  calculi  through 
the  intestine. 

The  correctness  of  these  dietetic  rules  is  strikingly  illustrated  in 
the  treatment  of  pancreatic  fistulse,  which  often  persist  after  injuries 
to  the  pancreas  by  shot  or  stab  wounds,  after  rupture,  and  par- 
ticularly after  operative  treatment  of  pancreatic  ducts.  When 
extirpation  is  impossible,  the  usual  procedure  is  to  suture  the 
cystic  sac  into  the  laparotomy  wound,  and  it  may  then  be  a 
matter  of  considerable  difficulty  to  effect  obliteration  of  this  sac 
or  of  the  fistula.  The  difficulties  are  increased  if  active  pancreatic 
juice  continues  to  be  secreted  after  the  operation,  because  it  softens 
and  digests  the  abdominal  integument  in  the  vicinity  of  the  fistulous 
opening  down  to  the  deepest  parts.  This  not  only  causes  great 
inconvenience  and  discomfort,  but  also  involves  danger.  The  per- 
sistent secretion  tends  to  weaken  the  patient  to  a  marked  extent 
and  may  possibly  cause  death. 

Based  upon  the  physiologic  facts  above  mentioned,  "Wohlgemuth 
has  repeatedly  achieved  excellent  results  by  the  complete  exclusion 
of  carbohydrates,  i.  e.  by  the  adoption  of  antidiabetic  diet — fistulse 
of  long  standing  being  thus  closed.  One  case  reported  was  of 
twenty-one  months'  duration.  His  method  is  the  following:  The 
diet  is  rigorously  antidiabetic,  fats  and  proteins  predominating, 
while  carbohydrates  are  excluded  as  far  as  possible.  With  care  in 
varying  the  menu,  this  regimen  may  be  carried  out  for  a  long  time 
without  any  great  difficulty.  Preference  is  therefore  given  to 
eggs,  meat,  fat,  fish,  butter,  cream,  milk,  cheese,  green  vegetables 
(asparagus,  spinach,  red  or  white  cabbage).  These  vegetables  are 
cooked  without  flour,  as  for  diabetic  patients,  but  with  plenty  of 
butter  and  fat.    If  necessary,  white  bread  may  be  replaced  by  aleu- 


NECROSIS  OF  Till-:  PANCREAS  631 

ronat,  Graham  bread  or  mutase.  When  this  did  has  been  adhered 
to  for  two  weeks  a  distinct  result  can  usually  be  observed.  Should 
the  fistula  not  be  closed  by  this  time  the  same  diet  is  to  be  con- 
tinued. This  dietetic  treatment  is  useless  it'  there  is  no  distinct 
reduction  of  the  secretion  alter  >i\  week-.  Wohlgemuth  believes 
that  in  these  cases  it  is  not  a  question  of  simple  pancreatic  fistula, 
but  of  complicated  anatomic  conditions.  After  the  fistula  has 
closed,  the  antidiabetic  regimen  is  continued  for  a  few  days  longer, 
gradually  passing  on  to  mixed  diet  with  very  careful  addition 
of  carbohydrates.  In  conjunction  with  this  diet,  bicarbonate  of 
sodium  is  frequently  administered,  a  teaspoonful  in  a  little  water 
about  half  an  hour  before  and  after  meals. 

Should  Wohlgemuth's  diet  fail,  there  is  nothing  left  but  surgical 
intervention  with  the  object  of  uniting  the  fistula  with  the  intes- 
tinal canal,  unless  simpler  measures  (cauterization,  tincture  of 
iodin)  obliterate  it. 

HEMORRHAGE  OF  THE  PANCREAS. 

Pancreatic  hemorrhages  occur  in  acute  inflammation  of  the 
gland,  but  may  also  occur  in  disturbances  of  the  circulation  and  in 
pulmonary  and  hepatic  affections  in  which  the  secretion  of  the 
pancreas  is  inhibited,  also  in  purpura,  scorbutus,  hemophilia,  and 
embolus  of  the  principal  pancreatic  artery.  The  hemorrhages  may 
be  slight,  or,  on  the  other  hand,  so  extensive  that  the  entire  organ 
is  enormously  distended  and  so  firmly  impacted  between  the 
duodenum  and  the  spleen  that  the  former  is  directly  occluded 
by  compression.  Cases  of  this  kind  are  to  be  regarded  as  in  ex- 
treme danger.  As  a  rule,  patients  succumb  rapidly  unless  help  is 
very  promptly  at  hand.  The  hemorrhage  begins  with  sudden  pains 
in  the  gastric  region,  nausea,  vomiting,  and  rectal  tenesmus,  and 
terminates  with  grave  collapse.  As  a  matter  of  course  the  diagnosis 
is  exceedingly  difficult.    The  only  available  treatment  is  operative. 

NECROSIS  OF  THE  PANCREAS. 

Total  or  partial  necrosis  of  the  pancreas  may  easily  occur  in 
cases  of  acute  pancreatic  inflammation  and  hemorrhage.  Pancreatic 
necrosis  proper,  which  occurs  independently  of  these  conditions,  is 
of  altogether  uncertain  origin.  It  may  perhaps  be  assumed  that 
the  pancreatic  juice,  which  is  normally  harmless  toward  the  pan- 
creatic parenchyma,  suddenly  overcomes  the  natural  defenses  of 
these  tissues,  leading  to  autodigestion  and  fat  necrosis  of  the 
pancreas,  and  further  on  to  fat  necrosis  of  the  omentum  and  peri- 
toneum. The  necrotic  process  gives  rise  to  acute  manife>tations, 
pain  in  the  gastric  region,  with  nausea,  vomiting,  meteorism,  and 
collapse.     There  may  be  manifestations  of  ileus,  and  the  patient 


632  DISEASES  OF  THE  PANCREAS 

may  succumb  to  the  first  attack.  In  favorable  cases  the  acute 
stage  may  be  overcome,  with  the  result  that  a  latent  stage  develops, 
the  necrotic  areas  becoming  encapsulated.  The  pancreas  is  at 
first  considerably  enlarged,  dark  red,  and  soft;  but  as  the  affec- 
tion continues  it  becomes  hard  and  firm,  distinctly  demarcated 
against  its  surroundings.  Finally  it  is  reduced  to  necrotic  pulp 
inside  its  own  capsule,  or  it  continues  to  become  harder  and  firmer 
until  it  lies  as  a  dead  organ  in  an  abscess  cavity.  Should  the 
necrosis  spread  beyond  the  pancreas,  and  active  pancreatic  juice 
invade  the  abdominal  cavity,  a  so-called  fatty  tissue  necrosis  will 
result.  Whenever  the  pancreatic  juice  comes  in  contact  with  fat, 
decomposition  of  the  neutral  particles  in  the  fat  cells  will  result. 
Throughout  the  pancreas  and  adjacent  region  are  found  yellowish- 
white  points,  from  a  size  just  discernible  to  the  size  of  a  pinhead, 
indicating  the  location  of  the  chemically  decomposed  fat. 

The  treatment  consists  in  opening  the  abscess  cavity  containing 
the  necrotic  tissue.    The  prognosis  is  very  bad. 


PANCREATIC  CYSTS. 

There  are  to  be  distinguished: 

(1)  Genuine  cysts,  hollow  spaces  invested  with  epithelium, 
resulting  from  proliferation  of  the  glandular  ducts  and  the  acini 
of  the  pancreas,  from  stagnation  in  the  flow  of  the  pancreatic 
juice,  or  from  degeneration  of  the  pancreatic  tissue,  as,  for  instance, 
after  infectious  diseases. 

(2)  Cystoid  structures  without  any  epithelial  lining,  which  may 
result  from  softening  of  the  enlarged  pancreas,  necrosis  of  some 
of  its  parts,  and  blood  effusions.  The  more  intense  the  pathologic 
processes  which  destroy  the  pancreatic  tissue,  the  more  rapidly 
the  cysts  develop.  The  comparative  rapidity  of  cyst  development 
therefore  admits  of  a  conclusion  in  regard  to  the  original  affection 
of  the  pancreas,  an  important  point  in  the  anamnesis.  Gradually 
the  cyst,  owing  to  its  increasing  size,  exerts  an  unpleasant  effect 
by  pressure  upon  the  neighboring  organs,  especially  the  stomach 
and  the  transverse  colon.  In  any  case  the  diagnosis  is  by  no  means 
an  easy  matter.  The  Roentgen  ray  and  bismuth  may  assist  in  the 
diagnosis  by  showing  a  uniform  curvature  on  the  left  of  the  stomach, 
due  to  pressure  of  the  cyst. 

Treatment. — The  only  remedy  is  laparotomy,  followed  by  sutur- 
ing the  cyst  into  the  laparotomy  wound,  with  unilateral  or  bilateral 
opening.  The  cyst  having  been  opened,  there  remains  its  gradual 
obliteration  by  the  measures  employed  in  the  obliteration  of  fis- 
tulse  (see  page  629),  particularly  "Wohlgemuth' s  diet. 


PANCREATIC  CALCULI  633 


TUMORS  OF  THE  PANCREAS. 


The  pancreas  is  subject  to  primary  sarcoma  and  carcinoma. 
The  latter  is  the  more  frequent  and  may  involve  the  whole  gland, 
the  head  or  the  tail,  or  the  duct  of  Vater.  Permanent  or  periodic 
pains  and  colic,  jaundice  and  early  cachexia  point  to  carcinoma. 
Oftentimes  the  tumor  cannot  be  palpated,  owing  to  sensitiveness 
and  to  the  ascites  which  is  present  in  most  cases.  Carcinoma  of  the 
head  of  the  pancreas  induces  progressive  jaundice.  A  common 
cause  of  symptomless  jaundice  is  malignant  disease  of  the  pancreas 
(see  page  614). 

Treatment. — A  radical  operation  is  impossible  in  most  cases. 
When  the  pylorus  is  occluded,  some  relief  may  be  afforded  by 
gastroenterostomy. 

PANCREATIC  CALCULI. 

Pancreatic  calculi  are  due  to  some  antecedent  defect  in  pancreatic 
function.  The  substances  of  which  the  calculi  are  composed  (lime 
salts,  cholesterol)  are  in  solution  in  normal  pancreatic  juice,  but 
are  precipitated  when  qualitative  changes  in  the  juice  take  place. 
Changes  of  this  kind  may  occur  as  a  result  of  bacterial  invasion 
from  the  intestine,  occlusion  of  the  excretory  ducts  from  stricture, 
or  compression  from  without.  Chronic  pancreatitis  likewise  plays 
a  role  in  the  etiology  of  this  affection.  The  catarrhal  secretion 
in  the  ducts  and  the  desquamated  epithelium  form  the  nucleus 
around  which  the  calculi  are  built  up.  The  latter  float  in  the  current 
of  the  secretion  toward  the  excretory  ducts  of  the  gland  to  the 
papilla,  where  they  meet  with  resistance;  if  this  resistance  is  not 
overcome,  stagnation  and  decomposition  of  the  secretion  results, 
leading  in  many  cases  to  the  formation  of  new  stones  behind  the 
original  one.  When  there  is  a  complicating  infection,  suppurative 
pancreatitis  may  easily  supervene,  likewise  necrosis.  In  the 
absence  of  any  infection  there  is  a  tendency  to  chronic  changes, 
chronic  pancreatitis,  and  cyst  formation. 

Among  the  clinical  manifestations  are  colic,  swelling  of  the  gland 
(which  is  sometimes  palpable),  and  expulsion  of  stones  (which  must 
be  carefully  looked  for  in  the  feces  when  pancreatic  calculi  are 
suspected).  Should  larger  stones  be  formed,  leading  to  stagnation 
of  the  secretion  and  chronic  pancreatic  changes,  there  will  be  the 
same  digestive  disturbances  as  are  observed  in  chronic  pancreatitis. 

Treatment. — The  internal  treatment  has  already  been  discussed 
(see  page  629).  If  the  diagnosis  of  pancreatic  calculi  is  in  all 
probability  correct,  surgical  treatment  may  be  instituted. 


634  DISEASES  OF  THE  PANCREAS 

PANCREATIC  INFANTILISM. 

This  rare  condition  is  due  to  abnormal  inhibition  of  pancreatic 
secretiori.  It  is  characterized  by  lack  of  bodily  and  sexual  develop- 
ment, and  as  a  result  of  the  arrest  of  pancreatic  secretion  a  condition 
of  chronic  enteritis  ensues  which  is  manifested  by  a  constant  diar- 
rhea associated  with  flatulence.  The  retarded  bodily  development 
and  the  chronic  diarrhea  are  the  main  clues  to  the  diagnosis. 

This  condition  can  be  completely  cured  by  the  administration 
of  pancreatic  extract. 


C  H  A  P  T  E  It  XXXI V . 

ACUTE  ENTEROCOLITIS. 

Acute   Intestinal  Catarrh — Acute  Gastroenteritis— Acute 

Colitis — Cholera  Morbus — Cholera  Nostras — 

Acute  Diarrhea. 

Primary  acute  intestinal  catarrh,  like  acute  gastric  catarrh,  is 
a  disease  of  quite  frequent  occurrence. 

Etiology. — Etiologically,  four  varieties  of  acute  intestinal  catarrh 
are  recognized: 

(1)  Acute  Infection*  Catarrh. — This  form  of  enteritis  is  of  bacte- 
rial origin.  The  Bacillus  coli  communis  and  the  Bacillus  enteritis 
apparently  play  an  important  role  in  the  etiology.  Numerous 
other  species  of  bacteria  are,  however,  frequently  found,  but  these 
have  usually  been  introduced  with  some  article  of  the  diet.  It 
also  seems  probable  that  acute  infectious  catarrh  may  be  induced 
by  the  agency  of  numerous  entozoa  and  endamebse. 

The  various  forms  of  colitis  which  occur  in  cases  of  chronic 
constipation,  due  to  stagnation  and  bacterial  decomposition  of  fecal 
matter  (colitis  stercoralis),  belong  under  the  general  classification 
of  infectious  catarrh. 

(2)  Alimentary  Catarrh. — Acute  intestinal  catarrh  may  be  caused 
by  the  ingestion  of  food  that  has  not  undergone  decomposition. 
Wholesome  articles  of  diet,  improperly  prepared,  insufficiently 
masticated,  and  ingested  in  excessive  quantities,  can  cause  it. 
Usually,  however,  it  is  due  to  food  or  drink  (water,  milk,  sausage, 
fish,  butter,  ice,  fruit)  which  contains  toxic  substances  (ptomains). 
The  warm  season  of  the  year,  and  tropical  climates,  by  favoring 
the  decomposition  of  foodstuffs,  contribute  to  the  prevalence  of 
intestinal  catarrhs. 

(3)  Catarrh  Due  to  Exposure  to  Cold. — There  can  be  no  doubt 
that  sudden  cooling  of  the  abdomen,  the  back,  or  the  feet  (wet 
feet),  and  cold  beverages,  may  induce  acute  intestinal  catarrh. 

(4)  Catarrh  from  Intoxication. — This  condition  may  be  due  to 
either  medicaments  or  poisons.  Among  drugs  that  produce  catarrh 
when  taken  for  a  considerable  length  of  time  are  preparations  of 
mercury  (even  when  injected  intramuscularly),  arsenic,  phosphorus, 
the  emetics,  drastic  purgatives,  turpentine,  copaiba,  etc.  The 
poisons  chiefly  to  be  considered  are  the  acids,  alkalis,  and  alcohol. 

Pathology. — Acute  catarrh  of  the  intestine  is  characterized  by 
swelling  and  relaxation  of  the  mucous  membrane.     According  to 


636  ACUTE  ENTEROCOLITIS 

the  intensity  of  the  disease,  the  mucous  membrane  is  reddened  in 
a  circumscribed  area  or  for  its  entire  length,  in  consequence  of 
hyperemia.  The  reddening  may  advance  so  far  as  to  become 
a  dark  purple  discoloration.  The  solitary  follicles  are  usually 
swollen,  though  Peyer's  patches  do  not  seem  to  be  involved.  The 
mucous  membrane  is  more  or  less  covered  with  mucus,  which 
may  appear  clear  like  glass,  cloudy,  or  stained  with  blood.  Small 
superficial  abrasions  of  the  epithelium  are  of  common  occurrence. 
The  contents  of  the  intestine  are  usually  fluid.  Microscopically 
there  may  be  recognized  distended  bloodvessels  of  the  mucous 
membrane  and  occasionally  minute  extravasations  of  blood.  The 
interspaces  between  the  crypts  of  Lieberkuhn  are  generally  dilated 
and  infiltrated  with  round  cells.  The  epithelium  of  the  glandular 
cells  is  frequently  opaque.  The  glands  themselves  are  often 
markedly  enlarged,  relaxed,  and  elevated  above  the  surface,  in 
consequence  of  infiltration  of  the  connective  tissue. 

Acute  intestinal  catarrh  is  most  frequently  localized  in  the 
large  intestine  (colitis)  exclusively.  In  many  cases,  however,  the 
small  intestine  is  simultaneously  affected;  this  condition  is  called 
mixed  catarrh.  The  noxious  agencies  above  named  induce  primarily 
an  acute  gastritis,  and  from  the  stomach  the  inflammation  extends 
to  the  intestine,  thus  forming  the  well-known  picture  of  acute 
gastroenteritis.  Disease  of  the  small  intestine  only  is  a  very  rare 
affection,  although,  according  to .  Nothnagel,  it  undoubtedly  does 
occasionally  occur.  An  isolated  acute  catarrhal  disease  of  the  duo- 
denum is  not  rare,  but  the  disease  is  usually  associated  with  acute 
gastritis  (gastroduodenitis) . 

Symptoms. — Among  the  first  symptoms  of  acute  intestinal 
catarrh  are  abdominal  discomfort  and  pain,  and  loss  of  appetite. 
The  characteristic  diarrhea  develops  early,  the  number  of  the 
stools  being  proportional  to  the  gravity  of  the  affection.  The 
evacuations  become  more  liquid  as  the  frequency  of  the  discharges 
increases,  and  the  abdominal  pains  tend  to  become  more  severe 
during  this  period.  With  coincident  acute  gastritis  the  symp- 
toms of  this  condition  may  lead,  perhaps  overshadow,  those  of 
the  intestinal  catarrh.  But  even  without  the  presence  of  gastritis 
there  may  supervene  great  discomfort,  nausea,  pressure  in  the 
epigastric  region,  and  occasionally  vomiting.  The  general  subjec- 
tive condition  depends  upon  the  intensity  of  the  catarrh;  in  mild 
cases  it  is  not  affected  at  all.  Moderately  severe  cases  are  usually 
attended  with  lassitude  and  sensations  of  weakness.  Severe  cases 
with  profuse  diarrhea  may  induce  an  alarming  condition  of  weak- 
ness, especially  in  young  patients  and  those  well  advanced  in  years. 
Fever  is  usually  absent  in  the  lighter  and  moderately  severe  cases; 
occasionally,  however,  there  may  be  high  fever.  Enlargement  of 
the  spleen  is  rare.  Albumin  and  casts  are  frequently  found  in  the 
urine  of  cases  of  severe  catarrh,  particularly  in  patients  advanced 


DIAGNOSIS  637 

in  years.  The  urine  soon  returns  to  a  normal  condition  with  the 
recession  of  the  catarrh. 

Examination  of  the  abdomen  will  occasionally  elicit  a  moderate 
diffuse  tenderness  to  pressure,  which  becomes  pain  when  the 
colon  is  involved.  Frequent  borborygmi  and  other  adventitious 
sounds  are  heard.  When  the  abdominal  walls  are  thin  it  is  some- 
times possible  to  observe  visually  the  acceleration  of  the  peristaltic 
movements. 

Diagnosis. — The  deciding  points  in  establishing  the  diagnosis  of 
acute  intestinal  catarrh,  and  for  the  localization  of  the  disease  in 
the  large  or  small  intestine  or  both,  are  ascertained  by  the  condi- 
tion of  the  alvine  discharges.  The  more  or  less  pronounced  liquidity 
of  the  feces  and  the  amount  of  mucus  present  are  characteristic 
points.  The  fecal  matter  of  acute  catarrh  of  the  large  intestine  is 
usually  of  a  dark  brown  color  and  offensive  odor,  and  there  may  be 
discerned  isolated  particles  of  mucus;  it  contains  easily  visible 
mucous-looking  floceuli,  transparent  or  turbid,  and  shreds  which 
are  occasionally  tinged  with  blood,  especially  in  cases  in  which  the 
inflammation  has  gained  in  intensity.  In  cases  of  catarrh  of  the 
small  intestine,  which  are  not  so  frequent,  the  stools  are  lighter  in 
color.  \Yhen  the  catarrh  is  of  great  intensity  the  evacuations  may 
be  actually  green,  this  color  being  caused  by  the  presence  of  unal- 
tered bile  pigment.  There  may  be  much  mucus,  in  small  lumps, 
intimately  mixed  with  the  feces,  imparting  to  the  stools  a  jelly-like 
consistency.  If  the  feces  contain  undigested  remnants  of  food, 
such  as  meat,  starch,  and  fat,  it  is  probable  that  the  small  intestine 
is  inflamed.  Fecal  particles  (mucous  floceuli,  fatty  residues,  or 
muscle  fibers)  that  become  green  on  the  addition  of  a  5-per-cent. 
solution  of  sublimate  (Schmidt's  sublimate  test — page  116)  furnish 
thereby  proof  of  the  presence  of  unchanged  bile  pigment.  Dark, 
mucoid,  offensive  stools,  containing  undigested  particles  of  food, 
indicate  the  simultaneous  existence  of  catarrh  of  both  the  small 
and  the  large  intestine. 

For  purposes  of  treatment  it  is  only  necessary  to  distinguish 
between  these  two  sections  of  the  intestinal  canal  in  localizing  the 
catarrh;  it  is  scarcely  possible  to  fix  exactly  the  particular  region 
affected  by  the  catarrhal  process.  The  fact  that  the  duodenum  is 
sometimes  the  seat  cannot  be  doubted,  and  this  condition  is  usually 
found  associated  with  acute  gastritis.  It  may  be  diagnosed  if 
jaundice  (catarrhal  icterus)  supervenes  in  acute  gastritis.  It  is 
not  necessarily  accompanied  by  diarrhea.  In  cases  of  duodenitis, 
examination  of  the  duodenal  contents  after  removal  with  the  duo- 
denal tube  shows  stringy  mucus,  Gram-positive  motile  bacilli,  and 
numerous  cocci. 

It  is  sometimes  difficult  to  differentiate  between  an  acute  grave 
colitis  and  a  mild  acute  dysentery.  It  is  also  occasionally  difficult 
to  distinguish,  during  the  first  days  of  the  disease,  between  an 


638  ACUTE  ENTEROCOLITIS 

acute  intestinal  catarrh  with  a  temperature  and  a  case  of  beginning 
typhoid  fever. 

Prognosis. — The  course  of  acute  intestinal  catarrh  is  usually 
favorable.  With  proper  care  complete  recovery  may  be  expected 
in  three  or  four  days,  often  sooner.  In  a  few  cases,  however,  there 
remains  a  certain  hypersensitiveness  of  the  intestine,  and  a  ten- 
dency to  recurrence  of  the  catarrh  after  slight  dietary  errors. 
Severe  catarrh  of  the  large  intestine,  of  several  weeks'  duration, 
may  occasionally  be  very  slow  in  healing;  some  cases  may  indeed 
resist  all  treatment  and  become  chronic.  Acute  enteritis  or  gastro- 
enteritis rarely  runs  a  serious  course;  but  profuse  diarrhea  may 
supervene,  evidently  under  the  influence  of  particularly  virulent  or 
toxic  microorganisms — a  view  that  is  confirmed  by  the  frequent 
occurrence  of  this  grave  form  of  disease  during  the  summer.  The 
evacuations  finally  consist  of  serous  exudate  with  mucous  and 
fibrinous  flocculi  thoroughly  mixed  with  pus  and  epithelium;  they 
are  whitish-gray,  resembling  rice-water,  of  alkaline  reaction,  and 
may  occur  as  often  as  twenty  to  thirty  times  a  day.  Violent  vomit- 
ing also  may  be  present.  The  quantity  of  urine  becomes  much  less 
in  consequence  of  the  great  loss  of  water,  and  anuresis  may  super- 
vene.. Albumin  and  casts  are  frequently  found  in  the  urine.  This 
intense  catarrhal  disease  of  the  intestine  is  frequently  sufficient  to 
completely  prostrate  even  vigorous  persons.  It  is  a  direct  menace  to 
life  in  the  case  of  old  people  and  children.  There  may  finally  occur, 
in  a  most  sudden  manner,  cramps  of  the  calves  of  the  legs,  hoarse- 
ness, coldness  of  the  extremities,  and  cardiac  collapse.  Because 
of  the  similarity  of  the  stools  to  those  of  Asiatic  cholera  patients, 
and  the  resemblance  of  the  clinical  symptoms  to  those  of  genuine 
cholera,  this  affection  has  been  termed  cholera  nostras,  or  cholera 
morbus.  Notwithstanding  the  gravity  of  the  symptoms,  the  disease, 
when  properly  treated,  usually  runs  a  favorable  course. 

Treatment. — Persons  subject  to  acute  intestinal  catarrh,  as 
taught  by  their  own  experience,  should  as  a  matter  of  prophylaxis 
guard  against  colds  and  against  errors  in  diet.  They  should  be 
advised  to  clothe  themselves  warmly,  and  to  wear  in  winter  a 
warm  flannel  or  woolen  abdominal  bandage  or  warm  undergar- 
ments. They  should  avoid  cold  beverages  and  foods,  and  coarse 
articles  of  diet  such  as  fresh  fruit,  radishes,  cucumbers,  and  salads. 
When  the  physician  is  called  to  treat  a  case  of  acute  catarrh  of  the 
intestine,  the  cause  of  the  attack  must  be  considered  first.  If 
it  can  be  ascertained  that  harmful  foods  or  infectious  substances 
have  been  introduced  into  the  stomach,  the  indication  is,  of  course, 
to  empty  the  intestine  as  rapidly  as  possible.  Nature,  indeed, 
assists  herself  in  these  cases,  for  the  decomposition  products 
accumulated  in  the  gut  stimulate  peristaltic  movements,  inducing 
diarrhea,  by  which  the  harmful  materials  are  expelled.  It  is  fre- 
quently observed  that   improvement  begins   after   a   number   of 


TREATMENT  639 

copious  diarrheic  discharges;  the  bowels  themselves  have  acted 
upon  the  etiologic  indication.  In  many  cases,  however,  the  spon- 
taneous evacuation  of  the  intestine  is  not  sufficient,  and  notwith- 
standing the  free  movement  no  improvement  takes  place.  In  such 
cases  nature  must  be  assisted,  that  the  elimination  of  the  noxious 
material  may  be  more  thorough.  Castor  oil  and  calomel  serve  this 
purpose.  The  former  may  be  given  in  tablespoonful  doses,  one 
tablespoonful  every  hour  until  effective.  Because  of  its  disagreeable 
taste  it  is  often  administered  in  gelatin  capsules  or  in  emulsions. 

The'  National  Formulary  gives  the  formula  of  emulsion  olei 
ricini,  which  contains  one-third  of  its  volume  of  castor  oil.  Three 
tablespoonfuls  is  the  average  dose. 

Calomel  acts  safely,  rapidly,  and  mildly,  without  causing  inflam- 
matory irritation  of  the  bowel.  It  is  given  in  doses  of  0.02  to  0.05 
Gm.  (^  to  1  grain),  two  or  three  such  powders  at  intervals  of  two 
hours. 

Gm.  or  Cc. 
1$ — Hydrargyri  chloridi  mitis  ....       0 1 5  gr.  viiss 

Sodii  bicarbonatis 1 1 0  gr.  xv 

Misce  et  ft.  chart,  no.  viii. 

Sig. — One  every  hour,  followed  by  a  Seidlitz  powder. 

Gm.  or  Cc. 
]$ — Hydrargyri  chloridi  mitis  ....       0 1 3  gr.  v 

Sacchari  albi 0 1 6  gr.  x 

Misce  et  ft.  chart,  no.  i. 
Sig. — Take  at  once,  to  be  followed  in  two  hours  by  a  tablespoonful  of  Rochelle 
salt. 

Instead  of  these  purgatives,  any  of  the  well-known  bitter  mineral 
waters  (see  page  254)  may  be  given.  When  the  stomach  is  involved 
the  bowel  should  be  emptied  by  means  of  enemata. 

The  evacuation  of  the  bowel  having  been  accomplished,  atten- 
tion must  be  given  to  the  care  of  the  stomach.  In  many  cases 
treatment  commences  without  previous  evacuation  of  the  bowels, 
no  toxic  or  irritating  material  being  present,  or  the  case  being  one 
of  catarrh  due  toa"  cold."  The  care  of  the  stomach  is  best  secured 
by  rest  in  bed,  the  duration  of  which  will  depend  on  the  severity 
of  the  attack.  Some  slight  cases  may  be  permitted  to  get  up  and 
around  as  soon  as  the  second  day,  but  in  obstinate  cases  rest  in 
bed  for  several. days  is  indicated.  While  in  bed,  hot  cloths  should 
be  applied  to  the  abdomen,  and  frequently  changed.  Dry  or 
moist  applications  may  be  made  by  means  of  the  "Priessnitz" 
bandage  (see  page  250). 

The  diet  is  of  great  importance  in  the  avoidance  of  irritation. 
It  is  better  not  to  allow  any  food  to  be  taken  during  the  first  twenty- 
four  hours,  that  the  decomposition  processes  in  the  intestine  may 
receive  no  encouragement.  Therefore,  on  the  first  day,  it  is  well 
to  prescribe  complete  abstinence,  or  only  an  apparent  nutrition 
consisting  of  thin  water  broths,  thin  meat  broth  (mutton  broth), 


.  640  ACUTE  ENTEROCOLITIS 

tea  with  cognac,  white-of-egg  water  consisting  of  one  white  of 
egg  to  200  Cc.  (7  ounces)  of  water  with  the  addition  of  a  little 
table  salt  and  cognac.  This  pseudonutrition  suffices  for  the  first 
two  days,  and  in  grave  cases  with  violent  diarrhea  and  colic  it 
may  be  continued  for  longer  periods.  During  the  first  days  it 
is  useful  to  administer  carminative  teas,  valerian,  peppermint, 
thyme,  fennel,  or  anise-seed.  Under  this  treatment  the  symptoms 
usually  improve  within  one  or  two  days.  A  somewhat  more 
copious  diet  may  then  be  allowed,  proceeding  with  great  care. 
The  food  should  be  free  from  liability  to  decomposition,  as  por- 
ridges (thoroughly  cooked  and  strained)  either  of  oat  or  barley 
meal,  tea  with  a  little  milk  or  claret,  cocoa,  acorn-cocoa,  black- 
berry decoctions,  whortleberry  jelly  or  wine,  and  soups  with  rice, 
tapioca,  leguminous  flours  and  infant-food  flours.  Sugar  should  be 
replaced  in  the  drinks  by  saccharin.  Should  there  be  much  thirst, 
milk  of  almonds  may  be  given;  but  always  freshly  prepared,  for  it 
decomposes  readily;  it  has  a  slightly  astringent  effect. 

Watching  and  controlling  the  bowels  carefully,  the  physician 
may  gradually  allow  a  more  varied  diet — bouillon  with  egg,  water- 
soaked  stale  bread  or  toast,  boiled  water  with  claret,  soups  with 
ground-up  stale  bread  and  sweetbread,  or  rice  and  hominy.  This 
diet  should  be  persevered  in  until  the  bowels  have  become  com- 
pletely quiescent,  the  evacuations  firm,  and  all  abdominal  pains 
and  sensitiveness  to  pressure  have  disappeared.  Only  now  more 
solid  food  may  be  taken,  such  as  scraped  meat  free  of  connective 
tissue,  squab,  chicken,  scraped  white  meat,  mashed  potatoes,  and 
vegetables  ground  fine  and  passed  through  a  sieve,  such  as  peas, 
lentils,  spinach;  with  cocoa  or  chocolate.  The  course  of  the  disease 
being  normal,  a  full  diet  is  soon  assimilable.  For  some  weeks, 
however,  foods  rich  in  cellulose  should  be  avoided,  such  as  radishes, 
carrots,  cabbage  and  fresh  fruit,  as  well  as  fatty  and  sour  sub- 
stances. Milk  is  to  be  avoided  during  the  first  days  of  an  acute 
intestinal  catarrh,  because  of  the  fact  that  in  occasional  instances, 
which  cannot  be  predetermined,  it  induces  diarrhea.  After  the 
patient  has  begun  to  partake  of  potatoes  or  other  specially  pre- 
pared solid  food,  milk  may  be  permitted,  either .  boiled  by  itself 
or  together  with  cocoa  or  chocolate.  The  astringent  effect  of 
three-day  kefir  seems  to  be  advantageous  in  acute  intestinal  catarrh. 

It  is  impossible  to  lay  down  a  diet  for  all  cases  that  will  be  non- 
irritating  and  easily  assimilable.  So  far  as  milk  is  concerned, 
although  it  often  proves  exceedingly  useful  when  given  in  small 
quantities,  yet  in  the  majority  of  cases  of  catarrh  of  the  small 
intestine  it  had  best  not  be  given.  Experience  has  shown  that  if 
the  small  intestine  is  put  at  rest  for  a  short  time  it  is  possible  to  give 
milk  later  and  with  good  result. 

Disease  of  the  large  intestine,  even  though  it  may  be  advanced, 
does  not  contra-indicate  the  use  of  milk;  on  the  contrary,  milk, 


Tin:  ATM  EXT  1,11 

especially  when  it  is  the  only  food  taken,  is  exceedingly  useful. 
In  achylia  gastrica  and  in  hyperchlorhydria,  milk  a->  a  diet  occupies 
first  place,  l>ut  it  should  be  omitted  when  there  i>  an  associated 
catarrh  of  the  small  intestine. 

To  obtain  a  complete  cure  it  is  absolutely  essential  to  persevere 
with  the  non-irritating  diet  for  as  long  a  time  as  possible.  In  this 
respect  one  should  be  rather  too  rigorous  than  lenient.  Should 
the  patient  lose  flesh  rather  rapidly  during  the  first  few  days,  one 
should  not  be  misled  and  permit  the  ingestion  of  larger  quantities 
of  food  in  order  to  prevent  further  loss  of  weight.  The  keeping  of 
the  affected  intestine  at  rest  is  the  paramount  consideration.  Upon 
recovery  the  patient  quickly  regains  all  he  may  have  lost  in  weight. 

Xothnagel  has  called  our  attention  to  the  following  truths 
regarding  the  treatment  of  catarrhal  inflammation  of  the  mucous 
membrane  of  the  intestine:  (1)  A  genuine  cure  of  an  acute  catarrh 
can  only  be  brought  about  through  the  regenerating  processes 
going  on  in  the  affected  tissues.  (2)  Complete  recovery  is  possible 
in  the  acute  form  of  intestinal  catarrh  only.  The  second  point  is 
especially  emphasized,  and  the  assertion  is  made  that  chronic 
intestinal  catarrh  is  difficult  to  cure.  It  is  therefore  of  the  utmost 
importance  to  prevent  the  acute  catarrh  from  becoming  chronic. 
This  can  be  accomplished  not  so  much  by  medication  as  by  a  well 
regulated  regimen.     A  constipating  diet  (see  page  172)  is  essential. 

In  patients  of  advanced  years  suffering  from  severe  intestinal 
catarrh  and  great  weakness  of  the  heart,  it  is  proper  to  allow  the 
administration  of  alcohol,  in  the  shape  of  punch,  tea  with  claret, 
or  cognac  and  water. 

Should  the  small  intestine  be  the  principal  seat  of  the  disease  it 
may  occasionally  be  necessary  to  greatly  reduce  the  ingestion  of 
water.  The  water  impoverishment  in  such  cases  may  well  be  met 
by  the  use  of  the  Murphy  drip  (see  page  239). 

Medicaments,  generally  speaking,  do  not  play  an  essential  part 
in  the  treatment  of  acute  intestinal  catarrh.  In  cases  with  obstinate 
diarrhea,  violent  abdominal  pains,  and  vigorous  peristalsis,  opium 
(see  page  274)  will  be  chiefly  relied  upon,  but  its  employment  in  the 
treatment  of  young  children  and  the  aged  demands  great  care.  In 
cases  of  persistent  vomiting,  opium  may  be  administered  in  the 
form  of  suppositories.  Opium,  however,  should  only  be  made  use  of 
for  a  few  days.  Should  constipation  continue  several  days  following 
the  use  of  opium,  it  may  be  safely  and  unhesitatingly  left  to  itself; 
but  if  it  should  continue  too  long,  or  if  it  should  occur  even  without 
the  taking  of  opium — a  rather  frequent  occurrence — purgatives 
should  never  be  employed;  instead  of  them,  enemata  of  soap-water 
or  oil  should  be  given  (see  page  223). 

In  excessive  peristalsis  of  the  intestine,  as  in  diarrhea  and  dysen- 
tery, benzyl  benzoate  is  often  of  great  advantage.     In  doses  of  2 

41 


642  ACUTE  ENTEROCOLITIS 

Cc.  (30  minims)  in  water  three  or  more  times  daily  it  promptly 
checks  the  diarrhea  (see  page  276). 

Astringents,  as  a  rule,  are  not  employed  in  acute  catarrh,  unless 
it  be  of  remarkably  long  duration.  For  children  and  old  people 
who  must  not  be  given  opium,  subgallate  of  bismuth  may  be 
administered — for  adults,  0.5  to  1  Gm.  (8  to  15  grains)  as  powder 
several  times  daily;  for  children  it  may  be  given  in  chalk  mixture: 


Gm.  or  Cc. 

1$ — Bismuthi  subgallatis 210 

5ss 

Misturse  creta?    .      .      .      .      q.  s.  ad    60  [0 

Sij 

Misce. 

Sig. — Teaspoonful  every  one  or  two  hours. 

Bolus  alba  triturated  in  water  has  recently  been  recommended, 
in  doses  of  60  to  100  Gm.  (§  ii-iij)  once  a  day,  before  breakfast.  We 
may  occasionally  cut  short  cases  of  acute  enteritis  without  any 
other  treatment.  Bolus  alba,  or  kaolin,  is  commonly  known  by 
the  name  of  porcelain  clay.  It  is  used  as  an  absorbent  powder, 
dusted  on  the  surface  of  the  body  in  irritable  skin  conditions. 
It  is  not  easily  affected  by  chemical  reagents.  Such  large  quantities 
as  above  specified  are  rather  disagreeable  to  take. 

Cardiac  tonics,  such  as  digitalis,  caffein,  strophanthus,  camphor 
and  alcohol,  are  to  be  given  from  the  commencement  of  the  treat- 
ment to  old  people  with  weak  heart. 

Cases  of  enteritis  caused  by  acids,  alkalis  and  poisons  are  to  be 
treated  as  stated  under  the  heading  Toxic  Gastritis,  and  by  the 
appropriate  antidotes. 

Treatment  of  Cholera  Morbus. — Besides  the  acute  intestinal 
symptoms  to  be  treated,  as  above  mentioned,  it  is  necessary  to 
employ  most  energetic  measures  in  combating  the  grave  general 
symptoms,  such  as  the  loss  of  water  from  the  body  and  the  collapse. 
Such  patients  have  to  be  kept  very  warm,'  with  hot  bottles  to  the 
feet,  the  bed  heated,  hot  fomentations  to  the  abdomen,  and  vigorous 
rubbing  of  the  extremities.  Stimulants  are  to  be  freely  given  in 
the  form  of  alcoholic  drinks,  such  as  punch,  and  hot  tea  with  claret 
or  brandy.  When  the  heart  is  weak,  camphor,  ether,  caffein  or 
digitalone  may  be  given  subcutaneously. 

In  acute  gastroenteritis  of  infants,  sea-water  plasma  has  been 
found  very  efficacious.  It  has  been  used  in  grave  cases  with  good 
results.  The  use  of  sea-water  in  such  cases  is  never  contra4ndicated. 
Rapid  recoveries  occur  in  babies  when  milk,  broths,  and  even  boiled 
water  are  vomited.  Not  only  does  vomiting  cease  after  two  of 
three  injections,  but  the  diarrhea  also  stops.  In  cases  of  extreme 
malnutrition  associated  with  acute  gastroenteritis  the  child  can 
frequently  take  milk  after  the  first  injection.  In  Paris  there  are 
special  places  called  "Sea-water  Dispensaries  for  Poor  People" 
where  the  children  are  brought  for  the  injection  of  the  sea-water 
plasma.    When  brought  to  these  dispensaries  for  treatment,  many 


THE  A  TMEN  T  OF  CHOLERA  MOUB  US  643 

of  the  cases  are  in  ;i  moribund  condition,  yet  the  mortality  is  only 
2  or  3  per  cent. 

In  the  treatment  of  infantile  gastroenteritis  with  sea-water, 
there  arc  two  important  recommendations  to  be  made:  first,  to 
avoid  all  antiseptic  internal  treatment;  and  second,  to  discontinue 
lavage  of  the  stomach  and  colon.  Should  there  be  constipation, 
a  glycerin  suppository  is  sufficient  every  second  or  third  day.  Sea- 
water  plasma  is  injected  in  the  scapular  region  of  infants;  the 
gluteal  region  is  so  frequently  soiled  that  the  scapular  region  is 
preferable.  The  amount  injected  varies  with  the  weight  of  the 
patient.  Infants  weighing  less  than  six} pounds  receive  30  Cc.  (1 
ounce)  and  those  weighing  eight  to  twenty  pounds  60  to  90  Cc.  (2 
or  3  ounces)  every  two  or  three  days.  In  grave  cases  the  injections 
can  be  given  every  day,  increasing  the  dose  to  100,  180  and  240 
Cc.  (3  to  8  ounces).  For  the  method  of  administration,  see  page 
423. 

Should  the  tissues  be  nearly  destitute  of  water,  physiologic 
saline  solution  may  be  administered  by  hypodermoclysis.  A  favor- 
able influence  on  the  general  symptoms  is  often  produced  by  the 
whole  pack,  with  subsequent  cool  rubbing. 

After  the  bowels  have  been  thoroughly  evacuated,  the  following 
has  been  found  valuable: 

Gm.  or  Cc. 

R> — Resorcinolis 3 10  gr.xlv 

Bismuthi  subnitratis 10  [0  Siiss 

Tannigeni     .........       4|0  3i 

Misce  et  ft.  pulv.  no.  xvi. 

Sig. — One  every  three  hours. 

For  the  relief  of  pain  after  the  bowels  have  been  thoroughly 
evacuated : 

Gm.  or  Cc. 

B; — Tincturae  opii  camphoratse      ...     30 

Bismuthi  subnitratis 15 

Misturse  cretae    .      .      .      .      q.  s.  ad    60 
Misce. 

Sig.— Teaspoonful  every  two  hours. 


o  5j 

0  5ss 

0  5ij 


For  the  relief  of  pain  after  the  bowels  have  been  thoroughly 
evacuated,  when  there  is  vomiting: 

Gm.  or  Cc. 

B;— Extracti  opii 0 1 06  gr.  j 

Olei  theobromatis,  q.  s. 
Misce  et  ft.  suppos.  no.  ii. 
Sig.- — Introduce  one  into  the  rectum,  and  repeat  in  two  hours  if  necessary. 


CHAPTER  XXXV. 

CHRONIC  ENTEROCOLITIS. 

Chronic  Intestinal  Catarrh — Chronic  Enteritis — Chronic 
Colitis — Chronic  Sigmoiditis. 

Enterocolitis  is  a  catarrhal  inflammation  of  the  mucous  mem- 
brane of  the  small  intestine  and  the  colon.  We  should  distinguish 
between  primary  and  secondary  chronic  intestinal  catarrh.  One 
of  the  most  frequent  causes  of  primary  intestinal  catarrh  is  an  acute 
enteritis  that  has  not  healed  or  that  has  been  imperfectly  treated. 
Moreover,  it  is  possible  for  all  those  injurious  agencies  which  irritate 
the  mucous  membrane  of  the  intestine,  mentioned  as  causes  of  acute 
catarrh,  to  give  rise  to  a  primary  chronic  catarrh  (errors  of  diet, 
frequent  colds,  habitual  employment  of  laxatives,  constipation). 
Secondary  intestinal  catarrh  generally  develops  as  a  consequence 
of  gastric  disease,  fermentative  dyspepsia,  or  chronic  affections  of 
the  gut  itself  (ulcers,  tumors,  stenoses,  and  appendicitis). 

Pathology. — At  the  beginning  of  the  disease  the  mucous  mem- 
brane is  swollen  and  hyperemia  The  solitary  follicles  and  Peyer's 
patches  are  likewise  swollen.  In  severe  cases  extravasation  of 
blood  may  take  place.  The  distended  solitary  follicles  may  break 
and  form  very  small  ulcers.  The  interstitial  tissue  in  such  conditions 
is  infiltrated  with  small  round  cells.  The  mucous  membrane  may 
become  covered  with  polypoid  granulations,  and  the  glands  may 
become  dilated  and  constricted  into  cysts  containing  mucus.  The 
glandular  epithelium  is  distinctly  loose  and  swollen  so  that  it  is 
easily  shed  from  its  base.  When  these  changes  persist  for  a  long 
time,  degenerative  changes  gradually  supervene :  many  of  the  glands 
perish,  the  mucous  membrane  becomes  attenuated  and  atrophic, 
and  the  interstitial  tissue  proliferates.  Previous  hemorrhages  are 
indicated  by  slaty-blackish  discoloration  of  isolated  regions  of  the 
mucous  membrane.  Should  the  disintegration  of  the  epithelium 
be  very  marked,  ulcers  may  form,  and  if  the  conditions  are  favor- 
able they  may  develop  into  large  catarrhal  sores. 

Chronic  catarrh  may  affect  anatomically  all  sections  of  the  small 
and  the  large  intestine.  Clinically  we  distinguish  chronic  catarrh 
of  the  small  intestine,  chronic  catarrh  of  the  large  intestine,  and 
combined  or  mixed  catarrh  (the  small  and  the  large  intestine  being 
diseased  simultaneously). 

Symptoms. — The  subjective  discomforts  alone  are  not  sufficient 
for  the  diagnosis  of  chronic  intestinal  catarrh.    These  discomforts 


DIAGNOSIS  645 

vary  exceedingly  in  proportion  to  the  intensify  ami  the  extent  of 
the  morbid  process;  sometimes  they  arc  entirely  absent,  and  the 
catarrh  is  only  recognizable  by  the  thin  consistency  of  the  stools; 
on  the  other  hand,  there  may  be  more  or  less  distress,  though  the 
stools  are  apparently  normal.  Frequently  the  troublesome  symp- 
toms disappear  completely  for  a  long  time.  The  rule  is  that  the 
distress,  pain,  and  pressure  sensations,  at  either  definite  or  fluc- 
tuating points,  are  more  pronounced  and  frequent  when  there  is 
marked  diarrhea  than  under  other  circumstances,  though  con- 
stipated patients  are  also  subject  to  attacks  of  pain,  flatulence,  and 
annoying  pressure  symptoms  in  the  lower  bowel.  Frequently 
constipation  and  diarrhea  alternate.  The  general  condition  of  the 
body  suffers  most  when  there  is  pronounced  diarrhea;  in  such 
cases  considerable  loss  of  weight  may  take  place.  When  the  catarrh 
persists,  nervous  symptoms  frequently  develop. 

Diagnosis. — The  diagnosis  is  determined  by  the  nature  of  the 
stool.  It  must  be  emphasized  that  the  alvine  discharges  in  catarrh 
of  either  the  small  or  the  large  intestine  may  be  diarrheic  or  firm, 
well  formed,  and  on  inspection  apparently  normal.  When  catarrh 
of  the  small  intestine  is  fully  developed,  diarrhea  usually  sets  in; 
constipation  is  rare.  In  catarrh  of  the  large  intestine  there  is  an 
equal  frequency  of  diarrhea  and  constipation.  The  presence  of 
mucus  in  the  feces  is  characteristic  of  catarrh  of  the  colon.  This 
mucus  is  evacuated  with  the  feces  or  may  be  demonstrated  by  a 
test  lavage  of  the  colon.  It  is  always  composed  of  rather  large  and 
coarse  shreds,  and  is  lighter  in  color  and  more  transparent  in  pro- 
portion as  its  origin  is  farther  up  the  intestine.  The  higher  up  in 
the  colon  the  mucus  originates,  the  smaller  are  the  individual  flakes 
and  the  more  uniformly  distributed  are  they  found  in  the  feces. 
Without  the  demonstration  of  mucus  it  is  impossible  to  diagnose 
catarrh  of  the  large  intestine  (see  page  121). 

In  making  a  diagnosis  of  chronic  intestinal  catarrh  we  should 
not  mistake  the  brownish  mucus  which  originates  in  the  lowest 
portion  of  the  rectum,  and  which  is  so  frequently  seen  in  cases  of 
chronic  constipation;  the  mucus  may  appear  as  a  thin  varnish- 
like coating  upon  the  hard  fecal  masses.  We  must  also  eliminate 
the  cases  where  an  enormous  quantity  of  mucus  is  found,  as  in 
enteritis  membranacea.  Catarrh  of  the  lower  section  of  the  bowel 
is  probable  when  there  are  evacuated  hard  scybala,  embedded, 
as  it  were,  in  membranes  of  mucus.  Furthermore,  the  test-diet 
stool  in  catarrh  of  the  colon,  either  the  diarrheic  or  the  consti- 
pated variety,  differs  from  the  stool  of  catarrh  of  the  small  intes- 
tine, inasmuch  as  in  the  former  the  food  is  properly  digested  and 
it  is  impossible  to  demonstrate  the  presence  of  biliary  coloring 
matter  (see  pages  131-132). 

The  stool  is  totally  different  in  catarrh  of  the  small  intestine. 
It  is  generally  soft  in  character  and  presents  evidence,  according 


646  CHRONIC  ENTEROCOLITIS 

to  the  intensity  of  the  catarrh,  of  a  disturbance  in  the  digestion 
performed  by  the  small  intestine.  Schmidt's  test  diet  reveals, 
on  both  macroscopic  and  microscopic  examination,  defects  in  the 
digestion  of  meat,  fat,  or  carbohydrates,  or  all  three.  In  these 
cases,  also,  the  presence  of  mucus  may  be  often  demonstrated. 
This  mucus  differs  from  that  produced  by  the  large  intestine, 
however,  in  that  it  consists  of  the  most  minute,  glassy,  transparent 
flocculi,  containing  few  cells,  a  very  few  nuclei,  and  a  large  number 
of  bacteria.  It  is  frequently  discolored  by  bile,  or  it  becomes  green 
in  color  on  the  application  of  Schmidt's  sublimate  test,  this  being 
absolute  proof  of  origin  in  the  small  intestine.  Should  the  sublimate 
test  (see  page  116)  be  negative,  bilirubin  crystals  are  occasionally 
demonstrable  microscopically. 

The  demonstration  of  bilirubin,  i.  e.,  of  unaltered  biliary  coloring 
matter,  by  means  of  the  sublimate  test,  may  also  be  performed 
on  the  other  constituents  of  the  feces,  and  a  positive  reaction 
always  points  to  catarrh  of  the  small  intestine.  When  the  diarrhea 
is  frequent  the  entire  fecal  discharge  occasionally  turns  green 
on  the  addition  of  sublimate,  or  when  the  passage  through  the 
intestinal  tract  is  very  rapid  it  looks  green,  even  without  the  addi- 
tion of  sublimate,  in  consequence  of  its  containing  unaltered  bile 
coloring  matter. 

When  it  is  found  impossible  to  prove  the  presence  of  mucus  on 
macroscopic  examination  of  the  feces,  this  does  not  infallibly  indicate 
that  there  is  no  catarrh  of  the  small  intestine — for  it  may  happen 
that  mucus  originating  high  up  in  the  gut  is  dissolved  and  digested 
before  reaching  the  large  intestine  (see  page  121).  Under  such  cir- 
cumstances the  importance  of  demonstrating  the  decomposition  of 
protein  in  the  feces  becomes  apparent  (see  page  117).  In  a  stool  con- 
taining decomposed  protein  there  are  found,  not  so  much  the  decom- 
posed remnants  of  protein  that  has  escaped  digestion,  as  the  albu- 
minous products  of  the  intestinal  mucous  membrane  itself  (mucus, 
pus,  serum,  blood) .  In  catarrhal  processes  of  the  mucous  membrane 
of  the  small  intestine,  therefore,  mucus  and  serum,  even  when 
they  cannot  be  demonstrated  macroscopically,  may  be  shown  with 
certainty  to  be  present  by  proving  the  existence  of  decomposed 
protein  in  the  feces.  This  proof  is  afforded  by  the  incubator  test 
(see  page  116),  in  which  an  alkaline  reaction  is  developed,  with  dark- 
ening of  the  feces  and  generation  of  gases.  The  same  conclusion  is 
arrived  at  when  protein  is  found  in  the  filtrate  of  the  feces  by  the 
acetic-acid-boiling  test  and  the  potassium  ferrocyanid  test.  Since, 
according  to  the  preceding  statements,  putrefaction  takes  place  in 
the  majority  of  cases  of  catarrh  of  the  small  intestine,  it  follows 
that  the  diarrheic  stool  in  such  cases  is  nearly  always  of  a  dark 
brown  color,  of  alkaline  reaction,  and  of  the  most  disagreeable, 
putrid  odor.  Actual  fermentative  stools  of  light  yellow,  frothy 
quality  may  be  passed  when  the  digestion  of  carbohydrates  is 


TREAT  ME  XT  647 

markedly  insufficient  and  the  production  <>l'  mucus  and  serum  is 
insignificant.  These  cases,  however,  are  rather  rare.  But  even 
in  these  cases  an  exact  analysis  of  the  feces  will  reveal  the  signs 
of  catarrh.  Feces  that  look  normal  may  be  passed  after  test  meals 
in  cases  of  slight  catarrh  of  the  small  intestine;  but  an  exact 
analysis  will  demonstrate  the  presence  of  mucus  or  decomposed 
protein.  In  mixed  catarrhs  these  two  varieties  of  stools  may  be 
combined.  Diarrheas  in  such  cases  are  quite  frequent.  An  exact 
fecal  analysis  is  therefore  essential  for  diagnostic  purposes  (Plate 
VIII). 

Blood  and  pus  are  found  in  the  feces  in  ulcerations  and  hemor- 
rhages. Blood  shows  itself  either  macroscopically,  as  bloody 
mucous  flocculi  and  pure  blood,  or  chemically,  when  the  diet  is  meat- 
free,  by  the  benzidin  test.  Pus  appears  in  the  form  of  markedly 
purulent  mucus  or  in  small  yellowish-white  globules,  which  are 
plainly  visible  when  the  triturated  fecal  matter  is  placed  on  a  black 
plate  (Plate  VI).  The  pneumatic  sigmoidoscope  is  often  helpful  in 
the  diagnosis  (Fig.  46). 

Prognosis. — -The  course  of  chronic  enteritis  is  always  long  and 
tedious.  There  can  be  no  doubt  that  recovery  does  take  place 
when  proper  treatment  is  faithfully  persevered  in.  Many  cases, 
however,  can  only  be  improved,  and  relapses  may  occur  from  indis- 
cretion in  diet.  When  severe  catarrh  and  diarrhea  persist,  the 
general  condition  may  become  greatly  disturbed,  resulting  in 
decided  loss  of  weight.  Complication  with  ulcers  occasionally 
causes  severe  symptoms,  and  will  be  considered  more  fully  under 
its  proper  heading. 

Treatment. —  Treatment  of  the  Cases  with  Diarrhea. — As  in  other 
intestinal  diseases,  the  principle  of  giving  rest  to  the  affected  organ 
must  govern  our  therapeutic  measures.  It  is  very  important  that 
patients  with  pronounced  catarrh  should  be  placed  in  bed  for 
several  weeks,  the  mind  also  being  kept  as  quiescent  as  possible. 
Only  in  light  cases  can  bodily  and  mental  exercise  be  permitted. 
In  the  moderately  severe  and  especially  in  grave  cases  a  regular 
"cure"  should  be  insisted  upon  if  the  circumstances  of  the  patient 
will  at  all  permit.  Such  a  cure  can  best  be  undertaken  in  a  private 
hospital  in  which  the  medical  direction  is  reliable  and  the  required 
therapeutic  measures  can  be  properly  applied.  The  results  of 
treatment  with  patients  who  are  compelled  to  follow  their  usual 
occupations  are,  naturally,  far  less  satisfactory.  In  such  cases, 
which  unfortunately  are  always  in  the  majority,  as  much  bodily 
and  mental  rest  as  possible  should  be  insisted  upon.  All  kinds  of 
sport,  swimming,  rowing,  bicycle  riding,  horseback  riding,  golf,  etc., 
must  be  interdicted. 

A  carefully  selected,  non-irritating  diet  is  of  the  greatest  impor- 
tance; for  complete  details  see  page  172.  When  the  small  intes- 
tine is  affected,  the  diet  must  be  guided  by  the  results  of  examina- 


648  CHRONIC  ENTEROCOLITIS 

tion  of  the  feces  after  a  test  diet;  it  should  always  be  antiputrid, 
because  in  most  cases  of  catarrh  of  the  small  intestine  putrefactive 
processes  are  well  marked.  Antifermentative  diet  will  also  have 
to  be  considered,  though  not  so  frequently.  It  is  not  necessary  to 
be  quite  so  careful  with  the  diet  in  cases  of  diarrhea  with  catarrh 
of  the  large  intestine.  This  is  especially  true  when  it  is  known  that 
the  small  intestine  is  healthy,  for  in  such  cases  even  solid  foods  are 
sufficiently  broken  up  before  reaching  the  colon.  The  small  intes- 
tine must  always  be  considered  in  the  treatment  of  cases  of  mixed 
catarrh. 

Zweig  gives  the  following  diet : 

Early  :  Acorn  cocoa  in  water ;  saccharin,  toast,  butter. 

Forenoon:     One  or  two  eggs,  toast,  butter. 

Noon:  Soup,  such  as  rice;  oatmeal  without  salt;  minced  meat  or  fish 

boiled  in  butter;  whortleberry  jelly,  rice  or  hominy;  noodles 

or  macaroni;  one  or  two  glasses  of  whortleberry  wine  or 

claret;  toast. 
Afternoon  :    As  in  the  forenoon. 
Supper:  Soup  as  at  noon;  minced  meat,  whortleberry  jelly,  one  glass  of 

whortleberry  wine  or  claret,  toast,  butter. 

Boas  prescribes  for  cases  of  moderate  severity  the  following  diet: 

8  a.m.     Acorn  cocoa  in  water;  saccharin,  toast  and  butter  (20  to  30  Gm.) . 
10  a.m.     One  cup  (200  Gm.)  of  porridge  of  rice  or  oatmeal;  wheat  meal  in 

veal  bouillon  (without  salt);  50  Gm.  roast  veal  or  beef  (minced), 
or  fried  fish  or  cold  meat  (no  ham) . 

1  p.m.  Thick  soup,  legume,  oatmeal;  hominy  with  the  addition  of  nutrose, 
tropon  or  eucasein;  whortleberry  soup,  200  Gm.;  bouillon,  rice 
or  hominy  (cooked  to  semisolid  consistency);  vegetables  or 
potatoes  mashed  (50  to  100  Gm.);  meat,  fish  (50  to  100  Gm.), 
butter  gravy.  Pudding  containing  a  little  yolk  of  egg  and  sac- 
charin. (All  fruits  except  whortleberry  jelly  are  forbidden.  No 
fruit  juices.)  Beverages:  whortleberry  wine,  Burgundy,  Camarite, 
Lima  Ruba  wine  and  old  claret.  (Sweet  wines,  champagne  and 
effervescent  drinks  are  not  permissible.) 

4  p.m.      Tea,  cocoa,  biscuits,  toast,  zwieback  with  butter. 

7  p.m.  Thick  soup.  Cold  or  warm  meat  (50  Gm.),  toast,  butter  (20  Gm.). 
One  or  two  glasses  of  whortleberry  wine  or  claret. 

9  p.m.      One  glass  of  hot  whortleberry  lemonade  or  a  hot  punch  with  sac- 

charin, or  tea  with  claret. 

When  the  dietary  measures  are  not  adequate,  medication  may 
be  necessary.  The  calcium  preparations  are  especially  recom- 
mended— calcium  carbonate  and  calcium  phosphate,  of  each  equal 
parts,  one  teaspoonful  three  times  daily  in  water.  This  may  also 
be  given  in  combination  with  bismuth  subnitrate. 

Gm.  or  Cc. 

R- — Calcii  oarbonatis, 

Calcii  phosphatis     ......  aa      30 1 0  §  j 

Bismuthi  subnitratis     .....      15 10  §ss 

Misce. 
Sig. — A  teaspoonful  three  times  daily,  stirred  in  water. 

Gm.  or  Cc. 

R- — Calcii  carbonatis 30 1 0  3  J 

Bismuthi  subgallatis 4|0  5j 

Misce. 
Sig. — One  teaspoonful  three  times  a  day,  stirred  in  water. 


TREATMENT  649 

If  the  intestinal  catarrh  is  complicated  with  hyperacidity,  the 
calcium  preparations  are  better  than  the  sodium  preparations, 
because  the  latter  may  increase  the  diarrhea.  The  treatment  with 
intestinal  sedatives  is  fully  described  on  pages  274-281.  In  the 
presence  of  fermentation  the  following  combination  may  be  used: 

Gm.  or  Cc. 

1$ — Resorcinolis 410  5j 

Bismuthi  salicylates 6  j  0  5iss 

Misce  et  ft.  chart,  no.  xii. 
Sig. — One  before  each  meal. 

It  must  not  be  forgotten  that  chronic  enteritis  may  be  caused  by 
microorganisms  or  their  toxins.  The  colon  bacillus  is  a  frequent 
offender.  An  autogenous  vaccine  would  be  valuable  if  one  could 
be  prepared.  A  polyvalent  stock  bacterial  vaccine  containing 
50,000,000  colon  bacilli  to  the  dose,  or  the  "sensitized"  vaccine,  can 
be  given  subcutaneously  once  a  week  with  absolute  safety.  The 
interval  between  doses  may  be  reduced  and  the  dose  increased  if  little 
or  no  reaction,  local  or  general,  follows  the  last  preceding  dose. 

Kaolin  (bolus  alba)  has  given  good  results  in  a  dose  of  60  to 
100  Gm.  (§ij-iij).  It  should  be  taken  in  a  large  volume  of  water 
in  the  morning,  before  breakfast. 

In  abdominal  pains,  opium  is  inadvisable  and  should  only  be 
administered  for  the  relief  of  an  irritating  tenesmus;  the  supposi- 
tory is  the  preferable  form.  Lavage  of  the  rectum  is  advantageous 
in  some  cases  of  catarrh  of  the  intestine,  and  should  be  given  as 
described  on  pages  232-236.  Enemata  of  Carlsbad  water  or 
whortleberry  decoctions,  or  of  insoluble  astringents  such  as  bismuth, 
are  frequently  of  great  benefit.  Enemata  containing  tannic  acid  or 
nitrate  of  silver  are  inadvisable. 

The  injection  of  hot  gelatin  solution  will  frequently  bring  about 
a  complete  cure  of  severe  chronic  catarrh  of  the  large  intestine, 
with  diarrhea,  which  has  resisted  all  other  measures.  The  sphincter 
ani  and  a  short  distance  above  are  extremely  sensitive  to  heat,  and 
consequently  the  solution  is  injected  through  a  tube  about  four 
inches  long,  with  the  patient  on  his  left  side.  From  30  to  60  Cc. 
of  a  10-per-cent.  solution  of  gelatin  in  water,  at  a  temperature  of 
113°  to  125°  F.,  is  injected.  The  patient  lies  still  for  two  hours 
afterward,  with  heat  applied  to  the  abdomen.  Gelatin  has  a 
soothing  action  on  the  inflamed  mucous  membrane,  while  the  heat 
induces  a  healing  hyperemia;  the  calcium  present  has  also  a 
favorable  influence  on  the  local  repair.  It  is  possible  that  the 
gelatin  may  check  the  secretion  of  readily  putrefying  material 
from  the  intestinal  walls.  This  assumption  is  sustained  by  the 
prompt  arrest  of  the  diarrhea  and  rapid  transformation  of  a  strongly 
positive  into  a  negative  response  to  the  incubator  test  (see  page  116). 
The  daily  injections  should  be  continued  for  eighteen  to  twenty- 
eight  days. 

The  use  of  mineral  waters  is  frequently  indicated  and  quite  effica- 


650  CHRONIC  ENTEROCOLITIS 

cious.  As  already  stated,  Carlsbad  water  has  a  curative  effect  in 
chronic  catarrh  (see  page  264).  If  Carlsbad  water  is  to  be  used  for 
any  length  of  time,  it  should  be  taken  in  small  quantities  only,  twice 
daily,  or  in  much  smaller  quantities,  30  to  60  Cc.  (Sj-ij),  three 
times  a  day,  very  hot.  The  cure  taken  once,  for  four  weeks  only,  is 
not  enough;  it  should  be  taken  at  least  four  times  during  the  year, 
one  month  at  a  time,  at  home.  The  waters  of  Saratoga  have  given 
good  results  in  cases  of  chronic  catarrh  of  the  intestine.  The 
drinking  of  the  calcium  waters  has  also  proved  quite  effective. 
Ferruginous  waters  are  to  be  employed  in  anemic  conditions  (see 
page  254). 

While  the  patient  is  resting  in  bed,  warm  applications  (wet  or 
dry),  thermophores,  or  Priessnitz  bandages  are  to  be  applied  to 
the  abdomen  during  the  day.  The  abdomen  must  be  kept  warm. 
It  is  also  very  advisable  that  a  warm  abdominal  bandage  be  worn 
for  some  little  time  after  this  resting  period  is  over.  Rubbing, 
washing,  sitz  baths  and  packs  are  to  be  used  in  addition.  (See 
Chapter  XII.) 

Treatment  of  the  Cases  Associated  with  Constipation. — Here,  also, 
both  bodily  and  mental  rest  are  quite  essential.  It  is  not  necessary, 
however,  to  insist  on  absolute  rest  in  bed  in  moderate  or  light 
cases.  The  diet  should  be  calculated  to  remedy  the  constipation, 
as  outlined  in  Chapter  VII  (see  pages  182-186).  In  this  pathologic 
condition,  however,  the  diet  must  act  only  chemically  on  the  con- 
stipation; mechanical  irritation  by  a  coarse  diet  rich  in  cellulose 
must  be  entirely  avoided.  The  cellulose  remnants  may  be  ade- 
quately replaced  by  large  quantities  of  agar,  30  to  60  Gm.  (1  or  2 
ounces)  per  day,  which  render  the  stools  soft  and  mushy  and  do  not 
irritate  the  mucous  membrane.  As  constipation  is  found  only  in 
catarrh  of  the  colon,  the  diet  may  be  a  little  heavier  than  if  the 
small  intestine  were  involved.  It  is  usually  possible  to  regulate 
the  stool  by  means  of  the  diet,  and  thereby  to  diminish  the  produc- 
tion of  mucus  in  the  colon. 

Should  dietetic  measures  fail,  enemata  should  be  used  as  adju- 
vants. A  solution  containing  table  salt,  lime-water  (three  or  four 
tablespoonfuls  to  a  liter  of  water)  or  bicarbonate  of  sodium  is  useful. 

Purgatives  are  strictly  to  be  avoided.  Liquid  petrolatum 
(refined  mineral  oil)  deserves  consideration  in  such  cases — its 
softening  effect  on  the  fecal  matter  being  very  desirable,  as  is  also 
its  emollient  effect  upon  the  mucous  membrane.  The  daily  dosage 
is  two  or  three  tablespoonfuls.  This  oil  (see  page  664)  has  been 
found  to  be  particularly  beneficial.  The  following  prescriptions  have 
been  found  useful: 

In  hyperacidity  with  diarrhea: 

Gm.  or  Cc. 

]$ — Bismuthi  subnitratis 15 1 0  5ss 

Calcii  carbonatis  precipitatis, 

Cretse  preparata? aa     30 10  §j 

Misce. 

Sig. — Teaspoonful  in  water  one  hour  after  meals. 


TREATMENT  65] 

In  hyperacidity  with  constipation: 

Gm.  or  Cc. 

1$ — Sodii  bicarbonatis 45 1 0  5  iss 

Magncsii  oxidi 15 10  5ss 

Misce. 

Sig. — Tcaspoonful  in  water  one  hour  :ifter  meals. 

For  abdominal  pain: 

Gm.  or  Cc. 

ty — Anesthesini 4|0  5j 

Misce  et  ft.  caps.  no.  xvi.  \ 

Sig. — One  every  three  hours. 

For  tenesmus: 

Gm.  or  Cc. 

1$ — Extracti  opii 0 1 06  gr.  j 

Extracti  belladonna: 0|03  gr.  ss 

Olei  theobromatis,  q.  s. 

Misce  et  ft.  suppos.  no.  iii. 

Sig. — -One  introduced  into  the  rectum  every  hour  if  necessary. 

As  an  astringent  and  intestinal  antiseptic: 

Gm.  or  Cc. 

1^ — Tannopini 15 10  gss 

Misce  et  ft.  pulv.  no.  xvi. 
Sig. — One  every  three  houirs. 

Ionization  with  a  2-per-cent.  zinc  sulphate  solution  has  been 
found  efficacious  in  the  treatment  of  chronic  enterocolitis  with  or 
without  ulceration.  The  method  of  application  is  simple,  easy,  and 
painless.  The  bowels  should  be  washed  out  with  warm  water,  to 
free  them  as  much  as  possible  from  gas,  fecal  material,  blood  and 
mucus.  A  large  pad,  8  by  10  inches,  covered  with  cloth,  is  dampened 
with  warm  saline  solution,  then  attached  to  the  negative  pole  of  a 
battery  and  applied  to  the  abdomen.  A  rectal  electrode  (Fig.  38) 
is  lubricated  and  inserted  into  the  bowel  just  above  the  sphincters. 
A  rubber  tube  attached  to  an  ordinary  irrigator  is  slipped  over  the 
free  end  of  the  rectal  electrode.  The  irrigator  is  fed  with  a  warm 
2-per-cent.  zinc  solution.  The  solution  is  allowed  to  flow  into  the 
bowel  until  it  is  estimated  that  the  whole  of  the  diseased  part  is  filled 
with  it.  The  positive  wire  from  the  battery  is  then  fixed  to  the  bind- 
ing screw  of  the  rectal  electrode,  and  the  current  is  turned  on  slowly 
up  to  15  to  30  milliamperes,  according  to  the  tolerance  of  the  patient, 
and  allowed  to  act  for  ten  to  fifteen  minutes.  If  the  bowel  is  irri- 
table it  is  advisable  to  first  insert  an  opium  suppository.  A  bed- 
pan should  also  be  placed  under  the  patient  in  case  there  should  be 
an  urgent  call  to  empty  the  bowel.  This  treatment  can  be  carried 
out  at  first  daily,  then  every  other  day,  and  later  twice  a  week. 
The  mucus  and  blood  will  soon  disappear  from  the  stool,  and  the 
colonic  pain  will  be  greatly  alleviated.  After  the  treatment  is 
finished  and  the  rectal  electrode  is  removed,  the  zinc  solution  is 
evacuated  by  the  bowel  in  the  ordinary  way.  •  (See  Chapter  XI.) 


CHAPTER  XXXVI. 
ENTERITIS  MEMBRANACEA. 

MuCOMEMBRANOUS   ENTERITIS  —  MUCOUS    COLITIS — PSEUDOMEM- 
BRANOUS Enteritis — Tubular  Diarrhea. 

The  morbid  process  known  as  enteritis  membranacea  owes  its 
name  to  the  peculiar  spastic  evacuation  of  considerable  quantities 
of  mucus  which  characterizes  it.  There  are  two  theories  concerning 
the  etiology  of  the  disease:  first,  that  the  spasmodic  excretion  of 
mucus  is  a  secretory  neurosis  (colica  mucosa,  colica  mucomem- 
branacea,  myxoneurosis  intestinalis  mucomembranacea)  without 
anatomic  affection  of  the  intestinal  mucous  membrane  (a  condition 
comparable  to  bronchial  asthma);  second,  that  the  cause  of  the 
disease  is  catarrh  of  the  colon  (colitis  membranacea,  enterocolitis 
mucomembranacea).  Recently  a  compromise  view  has  gained 
acceptance,  it  being  assumed  that  in  enteritis  membranacea  there 
are  both  nervous  irritation  and  membranous  inflammation.  The 
inflammation  may  be  circumscribed,  confined  to  small  regions 
of  the  mucous  membrane  of  the  colon,  and  giving  little  evidence  of 
its  existence.  There  is  always  a  derangement  of  the  vegetative 
nervous  system  (see  page  387).  These  patients  respond  to  all  the 
tests  for  vagotonia.  There  is  an  overstimulation  of  the  vagus, 
probably  through  the  internal  secretions.  The  nervous  irritation 
may  emanate  from  the  genitals,  from  mental  influences,  from 
constipation,  or  from  coloptosis.  Hypersensibility  toward  certain 
foods  or  certain  changes  in  temperature,  or  toward  particular 
positions  or  movements  of  the  body,  may  produce  a  reflex  nervous 
irritation.  It  is  evident  that  persons  of  nervous  temperament 
are  particularly  predisposed  to  this  malady.  Enteritis  membran- 
acea, however,  does  undoubtedly  occur  in  persons  who  are  by  no 
means  "nervous;"  it  cannot  be  viewed  as  a  local  symptom  of 
either  neurasthenia  or  hysteria.  This  is  proved  from  the  fact  that 
the  disease  is  occasionally  induced  by  irrigating  the  intestine  with 
irritating  astringents  such  as  silver  nitrate  or  tannic  acid. 

Pathology. — Up  to  the  present  time  no  pathologic-anatomic 
basis  has  been  discovered  for  this  disease.  All  authors  agree, 
however,  in  their  description  of  the  characteristic  symptoms  of 
the  disease — the  seizure-like  evacuation  of  mucus,  the  disturbances 
of  fecal  evacuation,  and  the  painful  intestinal  contractions.  Women 
constitute  from  80  to  90  per  cent,  of  all  cases;  the  age  incidence 
is  usually  between  twenty  and  forty.    The  patients  are  generally 


TUEATMKNT  653 

anemic,  weak,  exhausted  by  much  child-bearing.  The  affection 
is  rare  in  advanced  age  and  very  rare  iii  childhood,  so  Far  as  the 
published  reports  show. 

Symptoms.  Constipation  is  a  feature  of  the  large  majority  of 
eases,  and  diarrhea  is  rare.  Defecation  is  usually  attended  with 
pain  and  the  expulsion  of  mucus.  The  pains  come  on  beforehand, 
and  may  assume  an  exceedingly  violent,  colicky  character;  relief  is 
afforded  by  the  evacuation.  The  feces  often  resemble  those  of 
slice]),  and  suggest  spastic  constipation  (see  page  668).  Simultane- 
ously with  the  fecal  evacuation,  large  quantities  of  mucus  in  the 
shape  of  the  well-known  bands  are  expelled.  This  mucus  may  be 
ribbon-like,  three  or  four  inches  long,  in  irregular  shreds  of  various 
shapes,  or  in  the  form  of  regular  hyaline  casts  of  the  intestinal  tube. 
Occasionally  the  evacuation  of  mucus  takes  place  by  itself — the 
passage  contains  nothing  but  mucus.  The  course  of  events  is  by 
no  means  the  same  in  all  cases.  Occasionally  the  pains  are  very 
slight  or  even  entirely  absent,  and  sometimes  they  are  not  experi- 
enced with  every  act  of  defecation.  The  expulsion  of  membranes 
may  alternate  with  that  of  fecal  matter,  resulting  in  most  hetero- 
geneous aspects.  Other  objective  signs  may  be  present,  such  as 
occasional  tenderness  to  pressure  over  the  large  intestine;  this, 
however,  is  not  characteristic  of  the  disease.  After  the  disease  has 
continued  for  some  time  the  patients  usually  have  pronounced 
general  nervous  symptoms,  which,  coming  on  in  this  manner,  must 
be  regarded  as  a  consequence  of  the  affection  (see  page  133). 

The  course  of  the  disease  is  distinctly  chronic.  The  trouble 
often  lasts  for  many  years,  although  frequently  it  is  interrupted 
by  periods  of  from  one  month  to  three  months  of  well-being.  "With 
proper  treatment  cures  are  quite  likely  to  be  accomplished. 

Treatment. — The  treatment  is  directed  against  the  fundamental 
disease,  if  such  be  recognized  with  certainty  or  even  with  prob- 
ability. Therefore  great  stress  must  be  laid  on  the  proper  general 
treatment  of  nervous  patients  by  means  of  hydrotherapeutic, 
physical  and  electrical  measures.  Patients  deficiently  nourished  are 
to  be  subjected  to  an  invigorating  regimen;  hyperalimentation  (see 
page  569)  is  especially  beneficial  in  such  cases.  Should  enteroptosis 
be  present,  it  is  to  be  treated  by  suitable  abdominal  bandages  (see 
page  574);  and  anemic  conditions  are  to  be  counteracted  by  the 
usual  means.  Mental  irritation  must  be  avoided  as  much  as 
possible. 

This  disease  is  closely  connected  with  nervous  dyspepsia  and  with 
enteroptosis.  The  intestinal  condition  is  directly  dependent  on 
the  failure  of  the  stomach  to  perform  its  functions,  and  therefore 
therapeutic  measures  should  be  directed  to  the  basic  affection. 
The  abnormal  condition  of  the  stomach  (vagotonia)  irritates  the 
solar  plexus,  and  this  irritation  is  transmitted  to  the  intestinal 
plexus  and  thus  causes  the  intestinal  symptoms.    The  anomalies 


654  ENTERITIS  MEMBRANACEA 

of  the  gastric  functions  (principally  achylia)  and  enteroptosis 
exist  in  a  large  number  of  cases  of  membranous  enteritis.  As 
movable  kidney  and  enteroptosis  are  so  frequently  found  in  cases 
of  membranous  enteritis,  the  correction  of  these  displacements 
must  not  be  neglected.    (See  Chapter  XXX.) 

In  cases  associated  with  anemia  the  intramuscular  injection 
of  citrate  of  iron,  0.05  Gm.  (1  grain),  is  a  measure  of  great  advan- 
tage. The  hemoglobin  will  increase'  more  rapidly  under  this 
method  of  treatment  than  under  any  other.  i\rsenic  and  the 
glycerophosphate  of  sodium  can  be  combined  with  the  citrate  of 
iron  when  indicated.  The  cacodylate  of  sodium  or  iron,  0.05  Gm. 
(1  grain)  intravenously,  is  an  alterative  and  acts  well  on  the 
metabolic  processes  (see  page  581). 

These  measures  are  intended  to  combat  the  nervous  irritation 
which  is  so  closely  related  to  the  characteristic  symptoms.  The 
inflammatory  part  of  the  disease,  viz.,  the  more  or  less  pronounced 
circumscribed  cellulitis,  and  the  constipation,  require  careful  con- 
sideration. The  regulation  of  the  diet  is  of  prime  importance,  and 
with  this  in  view  various  suggestions  have  been  offered.  It  is 
evident  that  the  diet  will  have  to  be  abundant,  in  order  to  increase 
nutrition  as  much  as  possible  and  antagonize  the  constipation.  A 
non-irritating  diet  is  by  no  means  indicated,  for  the  small  intestine 
is  normal  and  is  able  to  cope  with  an  abundance  of  hardy  food. 
Some  authors,  e.  g.  von  Noorden,  propose,  as  applicable  throughout 
the  entire  course  of  enteritis  membranacea  with  constipation, 
a  diet  consisting  of  coarse  articles  rich  in  cellulose  (coarse  bread, 
legumes,  fruit  containing  small  seeds  and  thick  skins,  vegetables 
rich  in  cellulose),  as  described  in  Chapter  YII  on  Diet.  Fat  should 
always  be  a  prominent  part  of  the  diet.  The  commencement  of 
this  dietetic  treatment  should  be  quite  abrupt.  Zweig  publishes  a 
list  which  corresponds  essentially  to  this  kind  of  diet : 

Emily:  Tea  with  milk.     Graham  bread,  butter,  honey. 

Forenoon:        One  glass  of  one-day  kefir.    Pumpernickel,  black  bread,  butter. 

Noon:  No  soup.     Meat  or  fish;  vegetables;  salad  with  vinegar  and 

oil;  pudding  with  sweet  fruit  juice;  jam;  fruit  (grapes,  dates, 

figs,  oranges);  Graham  bread.     Apple  juice,  one  glass. 
Afternoon:      Chocolate    with    whipped    cream.     Graham    bread,    butter, 

marmalade. 
Evening:  Eggs,  or  bacon  and  eggs,  meat  (cold  or  warm);  salad;  jam; 

Graham  bread,  butter,  cheese,  fruit.     Apple  juice,  or  one 

glass  of  white  wine. 
10  p.m.  One  glass  of  kefir  (one-day). 

The  coarseness  of  this  diet,  however,  might  in  some  cases  lead 
to  irritation  of  some  portion  of  the  mucous  membrane  of  the  colon 
which  is  already  irritated.  Many  authors  therefore  advise  a  con- 
stipating diet,  more  stress  being  laid  upon  its  chemical  action  than 
upon  its  richness  in  insoluble  remnants  of  food.  The  type  of  this 
diet  is  the  one  given  in  cases  of  spastic  constipation  (see  page 
185),  in  which  the  percentage  of  calories  is  increased  as  much  as 


TREATMENT  655 

possible  by  the  addition  of  fat.  In  ease  it  is  desired  to  add  more 
insoluble  ingredients,  the  procedure  of  Schmidt  might  be  followed — 
the  daily  administration  of  a  considerable  quantity,  30  to  60  Gm. 
(1  or  2  ounces),  of  finely  divided  dry  agar;  an  alternative  method 
would  be  to  give  the  agar  in  the  form  of  jelly-like  foods.  This 
material  renders  the  stools  soft,  mushy,  and  rich  in  water.  It 
represents  a  kind  of  coarse  food,  the  irritation  caused  by  it  being 
slight,  however,  in  comparison  with  that  caused  by  hard  cellulose 
remnants;  it  is  well  adapted  to  assist  the  purgative  action  of  a 
chemically  active  diet.  The  addition  of  gelatin  to  the  food  might 
likewise  be  indicated.  Quite  recently  it  has  become  customary 
to  recommend  a  diet  poor  in  meat,  or,  better  yet,  one  free  from 
meat,  i.  e.  a  lactovegetable  diet  (see  page  422).  The  results  obtained 
from  this  diet  have  been  quite  good. 
Ewald  prescribes  the  following  lactovegetable  diet: 

Early:  |  liter  sweet  cream  or  cocoa  or  oatmeal-cocoa;  white  or  black 

bread  with  butter;  honey,  marmalade,  or  fresh  fruit. 

Forenoon:        Porridge  of  rice;  lentils,  hominy;  milk,  kefir;  white  or  black 
bread  with  butter. 

Noon:  Leguminous  or  fruit  soups  (apple,  plum,  cranberry,  raspberry, 

gooseberry,  cherry);  vegetable  soups  (spinach,  carrot, 
tomato);  milk  soups  or  cold  soups;  fruit  juices;  gooseberries; 
black  bread  and  raisins  (small);  buttermilk  or  sour  milk. 
This  is  to  be  followed  later  by  plenty  of  green  vegetables  (with 
as  much  butter  as  agreeable),  or  instead  of  the  vegetables 
mashed  peas,  lentils,  rice  with  apples  (if  desired),  dried  fruit 
with  dumplings,  macaroni,  pudding  melange  with  fruit 
sauce,  salads,  egg  dishes,  bread  and  butter,  fresh  cream 
cheese. 

Afternoon  :      Boiled  or  fresh  fruit  plentifully,  with  zwieback  or  white  bread; 
honej'  or  fruit  jellies. 

Evening:  Thick  soup  of  barley,  oats,  rice,  hominy,  tapioca,  etc.;  fried 

potatoes;  butter,  cheese,  eggs  and  dishes  prepared  from 
eggs,  milk,  etc. 

Should  diarrhea  be  present,  a  residue-free  diet  is  indicated, 
embracing  especially  cream,  zwieback,  rice,  and  chocolate.  Coffee, 
wine  and  tobacco  are  to  be  forbidden. 

The  enteritis  must  receive  attention,  and  be  properly  treated 
locally  apart  from  dietetic  measures.  The  painful  crises  can  fre- 
quently be  relieved  by  the  use  of  pancreatin  in  combination  with 
bile.  Sodium  bicarbonate  can  be  added.  Not  only  the  pain  but 
the  character  of  the  stools  seems  to  be  relieved  by  this  combination. 

Fleiner's  oil  enemata,  used  constantly,  have  given  good  results 
(seepage  226). 

Irrigations  of  the  large  intestine  with  0.9-per-cent.  sodium  chloride 
solution  are  likewise  recommended,  and  especially  irrigations  with 
sodium  bicarbonate,  Carlsbad  water,  and  solutions  of  the  Carlsbad 
salts.  Astringents,  especially  silver  nitrate  and  tannin,  are  strictly 
contra-indicated.  Duodenal  lavage  is  especially  advantageous  (see 
page  105). 


656  ENTERITIS  MEMBRANACEA 

The  main  clinical  feature  of  membranous  enteritis  is  great 
irritability  of  the  muscular  coat  of  the  intestine.  This  may  result 
either  from  undue  irritation  of  the  autonomic  nervous  mechanism 
or  from  local  causes.  As  to  the  local  irritant,  this  may  be  either 
some  toxin  absorbed  from  the  bowel  or  some  substance  circulating 
in  the  blood.  The  colon  contains  an  abnormal  amount  of  some 
irritating  toxin  or  other  substance  which  normally  is  present  in 
small  amounts  or  not  at  all;  the  excess  is  due  to  bacterial  activity. 

An  autogenous  bacterial  vaccine  should  be  of  great  benefit  in 
this  condition.  Good  results  are  often  obtained  from  colon  bacillus 
vaccine.  The  pain  and  mucus  diminish,  and  the  general  health 
improves.  The  colon  is  particularly  hospitable  to  bacteria,  con- 
taining, even  under  normal  conditions,  a  much  greater  number 
than  any  other  part  of  the  intestinal  tract.  One-third  of  the  weight 
of  dry  feces  is  said  to  consist  of  bacterial  bodies. 

When  it  is  impossible  to  regulate  the  bowel  evacuation  by  means 
of  dietetic  measures  alone,  it  will  be  necessary  to  occasionally 
resort  to  laxatives.  Only  mild  laxatives  are  to  be  employed, 
however,  e.  g.,  castor  oil,  rhubarb,  tamarind,  and  liquid  petrolatum. 
Cascara-agar  is  even  better  than  any  of  these,  because  it  exerts  an 
agreeable  and  to  a  certain  extent  peculiar  non-irritating,  softening 
and  exceedingly  mild  laxative  action  (see  Chronic  Constipation, 
page  659).  A  considerably  smaller  quantity  of  cascara-agar  is 
required  than  of  pure  agar,  one  or  two  tablespoonfuls  per  day  being 
sufficient.  Atropin  is  a  most  efficacious  therapeutic  agent  in  enteritis 
membranacea,  a  manifestation  of  vagotonia  (see  page  388).  In 
case  of  intestinal  spasms  with  subsequent  constipation  and  pains, 
narcotics  may  be  necessary  and  may  be  used,  as  opium  and  bella- 
donna suppositories.  The  extract  of  belladonna,  0.0075  to  0.015  Gm. 
(s  to  J  grain)  three  times  a  day,  is  very  valuable.  Hot  carminative 
teas  have  a  modifying  effect  on  the  spasm.  The  bromids  are,  as  a 
rule,  of  little  value.  Papaverin  and  benzyl  benzoate  are  valuable 
antispasmodics  (see  page  276) . 

Hydrotherapeutic  measures  are  useful  adjuncts  in  the  relief  of 
attacks  of  pain,  e.  g.  warm  abdominal  packs  and  warm  sitz  baths 
(100°  F.).  Half -baths,  douches,  water  pourings,  packs,  climatic 
changes,  or  sojourn  in  the  mountains  or  at  the  seashore  may  be  of 
great  benefit.  Extended  vacations  far  away  from  business  cares 
are  always  favorable  to  recovery  (see  page  247) . 

Very  light  massage  of  the  abdomen  (effieurage)  is  occasionally 
useful,  as  is  also  the  percutaneous  application  of  a  weak  galvanic 
current  (see  page  211). 

High-frequency  currents  are  beneficial  in  some  cases  of  mucous 
colitis.  High-frequency  treatment  is  given  on  the  condensor 
couch,  through  the  hands,  for  ten  minutes,  followed  by  fifteen 
minutes'  local  application,  sometimes  from  the  low  tension  and 
sometimes  from  the  resonator.    This  results  in  improvement  of  the 


TREATMENT  657 

general  condition,  and  the  pain  gradually  diminishes.  The  treat- 
ment should  be  continued  for  several  months  to  accomplish  a 
complete  cure. 

Sea-water  plasma  injections  have  given  good  results  in  some 
cases  of  enteritis  membranacea.  The  beneficial  effect  is  brought 
about  through  the  medium  of  the  nervous  system.  After  five  or 
six  injections  pain  and  the  excretion  of  mucus  cease  and  the  evacua- 
tions become  well  formed  and  regular.  The  distention  and  weight 
in  the  abdomen  gradually  subside  without  the  necessity  of  a  rigid 
diet. 

The  injections  are  first  given  in  doses  of  30  Cc.  (§  j)  every  two  or 
three  days.  Should  the  patient  be  extremely  nervous,  it  is  better 
to  begin  with  20  Cc.  Should  there  be  any  temperature  or  general 
malaise  after  the  injection,  the  dose  should  be  diminished  or  the 
interval  between  the  injections  lengthened.  In  case  there  is  no 
reaction  and  no  improvement  in  the  digestive  symptoms,  the 
amount  of  sea-water  administered  at  a  single  injection  is  to  be 
gradually  increased  to  40,  50,  75,  and  100  Cc.  These  injections 
should  be  given  intramuscularly  in  the  gluteal  region,  preferably  at 
bedtime.  The  treatment  can  be  continued  during  the  menstrual 
period  (see  page  423) . 

Mineral-water  cures  are  not  indicated;  they  overstimulate  secre- 
tion and  often  do  a  great  deal  of  harm. 

The  treatment  of  enteritis  membranacea  will  always  be  most 
successful  when  it  is  possible  to  remove  the  patient  from  his  domestic 
surroundings  and  to  place  him  in  a  private  institution  that  is 
devoted  especially  to  the  treatment  of  this  class  of  cases,  and  where 
all  the  therapeutic  apparatus  is  at  hand.  This,  unfortunately, 
is  impossible  in  general  practice,  as  the  greater  number  of  the 
patients  are  compelled  to  be  actively  engaged  either  at  home  or 
in  business;  furthermore,  these  "cures"  in  special  institutions  always 
demand  considerable  pecuniary  expenditure. 

Attempts  have  been  made  to  cure  the  disease  by  surgical  means, 
such  as  the  establishment  of  a  temporary  artificial  anus,  temporary 
colotomy,  or  partial  resection  of  the  colon.  The  results  obtained 
by  these  procedures  are,  however,  of  a  very  doubtful  nature. 

The  clinical  evidence  in  favor  of  surgical  intervention  in  cases 
of  mucus  colitis  is  not  convincing.  Cases  of  chronic  constipation 
with  colonic  irritation  are  at  times  diagnosticated  as  true  mem- 
branous colitis,  and  have  been  cured  by  colonic  irrigation.  Some 
surgeons  advocate  colonic  irrigation  through  appendicostomy 
(Fig.  104).  The  vermiform  appendix  is  fixed  to  the  abdominal 
wall  and  its  lumen  used  to  introduce  fluids  into  the  cecum  for 
irrigating  the  colon.  The  irrigating  fluid  passes  through  the  whole 
of  the  large  intestine  and  is  evacuated  by  way  of  the  rectum. 

A  chronic  appendicitis  may  occasionally  be  the  cause  of  mucous 
colitis.    There  is  no  doubt  that  the  removal  of  a  chronically  inflamed 
appendix  will  assist  in  the  recovery  of  some  patients. 
42 


658  ENTERITIS  MEMBRANACEA 

The  following  prescriptions  have  been  found  useful : 
To  relieve  pain  due  to  intestinal  spasm: 

Gm.  or  Cc. 

1$ — Pulveris  opii 0|03  gr.  f 

Extracti  belladonnse      .....       01008  gr.  | 

Extracti  hyoscyami 0|015  gr- I 

Misce  et  ft.  suppos.  no.  i. 

Sig. — To  be  introduced  into  the  rectum. 

For  the  relief  of  vagotonia: 

Gm.  or  Cc. 
1$ — Extracti  belladonna? 0 1 125  gr.  ij 

Misce  et  ft.  caps.  no.  xvi. 
Sig. — One  three  times  a  day. 

Carminative  tea  to  relieve  enterospasm: 

Gm.  or  Cc. 

1$ — Herbse  matricarise 30 

Seminis  feniculi 4 

Herbse  thymi      .  30 

Herbse  melissse 30 

Misce. 

Sig. — Dessertspoonful  in  a  cup  of  boiling  water  as  a  tea. 

Mild  laxative: 

1$ — Extracti  belladonnse 0 

Phenolphthaleini     .... 

Pulveris  aromatici  .... 
Misce  et  ft.  caps.  no.  xvi. 
Sig. — One  or  two  capsules  at  night. 

For  local  application  during  painful  colics: 

Py — Olei  hyoscyami  compositi  . 

Extracti  opii 5 

Extracti  belladonnse 

Chloroformi 

Chloralis  hydratis, 

Camphorse, 

Mentholis aa, 

Misce. 

Sig. — Saturate  flannel  and  apply  to  abdomen 


0 

Si 

0 

Si 

0 

Si 

0 

Si 

Gm. 

or  Cc. 

0 

1 

2 

125 

0 

0 

gr- U 
gr.  xv 
gr.  xxx 

Gm.  or  Cc. 

100 

5 

1 

20 

0 
0 
0 
0 

Biij 

3i 

gr.  xv 
3v 

,       1 

0 

gr.  xv 

CHAPTER  XXXVII. 

CHRONIC  CONSTIPATION. 

Atonic  Constipation;  Spastic  Constipation;  Fragmentary 
Constipation. 

Chronic  constipation  consists  of  infrequent  or  difficult  evacua- 
tion of  the  bowels.  It  must  not  be  confounded  with  obstipation, 
which  is  usually  from  a  mechanical  cause,  such  as  strictures,  an- 
gulations, adhesions  and  tumors.  (See  Chapters  XLYI,  XLYII 
and  XLATII.)  Chronic  constipation  may  be  divided  into  three 
varieties : 

I.  Atonic  Constipation. 
II.  Spastic  Constipation. 
III.  Fragmentary  Constipation. 

ATONIC  CONSTIPATION. 

Primary  atonic  constipation  is  one  of  the  most  common  diseases 
met  with  in  general  practice.  It  is  not  peculiar  to  either  sex, 
though  found  more  frequently  in  females  than  in  males.  The 
etiology  is  apparently  not  the  same  in  every  case.  Nothnagel 
held  the  cause  of  primary  atonic  constipation  to  be  an  abnormal 
innervation  of  the  intestine — an  abnormal  tonus  of  the  peristalsis 
of  colon  and  rectum,  followed  by  atony.  He  also  asserts  the  oc- 
casional occurrence  of  insufficient  muscular  activity  of  the  intestine 
in  consequence  of  hereditary  atrophy  of  the  intestinal  muscle  fibers. 
Emminghaus  has  found  degenerative  changes  in  the  splanchnic 
nerves.  There  can  be  no  doubt,  however,  that  alimentary  errors 
may  cause  chronic  constipation;  for  example,  an  improper  meat 
diet,  an  insufficient  quantity  of  food,  and  irregularities  in  the  time 
of  eating.  Chronic  constipation  may  be  a  part  symptom  of  a  dis- 
turbance of  the  vegetative  nervous  system  (see  page  387),  as 
vagotonia  or  sympathicotonia,  of  neurasthenia  or  hysteria,  or  of 
the  enteroptotic  habit.  The  latest  theory,  which  explains  a  large 
number  of  cases  of  chronic  constipation,  has  been  propounded  by 
Adolf  Schmidt,  Strasburger,  and  Lohrisch.  Schmidt  and  Stras- 
burger  had  noted  that  the  test-diet  stool  of  atonic  constipation 
patients  contained  a  remarkably  small  residue  of  food,  much  less 
than  the  test-diet  normal  stool,  on  both  macroscopic  and  micro- 
scopic examination.  Lohrisch,  after  having  made  a  systematic 
study  of  absorption,  explains  this  peculiar  phenomenon  as  follows: 


660  CHRONIC  CONSTIPATION 

When  the  feces  of  individuals  suffering  from  chronic  constipation 
and  those  with  normal  evacuation,  both  having  been  fed  identically, 
are  collected  within  the  same  space  of  time,  it  is  found  that  both 
the  moist  and  the  dried  quantities  of  fecal  matter  are  only  half  as 
large  in  those  suffering  from  constipation  as  in  the  normal  indi- 
viduals. This  small  quantity  of  fecal  matter  found  in  chronic 
constipation  depends  on  the  fact,  as  is  shown  by  analysis,  that  the 
feces  of  constipation  contain  only  half  as  much  protein,  fat,  carbo- 
hydrate and  cellulose  as  the  normal  feces  under  a  similar  diet. 
The  small  amount  of  moisture  is  due  not  only  to  a  larger  loss  of 
water  from  prolonged  retention  of  the  feces  in  the  bowel,  but  also 
to  an  extraordinarily  effective  utilization  of  the  food.  This  util- 
ization, compared  with  that  in  health,  is  too  effective.  Simulta- 
neously there  are  absent  from  such  constipation  feces  all  the 
phenomena  of  putrefaction  and  of  fermentation.  One  effect  of  this 
too  marked  utilization  of  the  food  is  that  the  intestinal  bacteria 
of  fermentation  and  putrefaction  cannot  flourish  in  so  poor  a  nutri- 
tive medium  as  the  exhausted  feces,  and  consequently  the  intestine 
is  deprived  of  the  stimulus  of  large  quantities  of  fermenting  and 
putrefactive  products,  with  the  result  that  intestinal  motility  is 
retarded  and  atonic  constipation  follows.  The  correctness  of  these 
researches  has  been  confirmed  by  other  authorities,  and  thus 
an  explanation  is  afforded  for  a  very  large  proportion  of  those 
cases  of  chronic  constipation  in  which  small  quantities  of  hard 
fecal  masses,  dry  and  nodulated,  are  evacuated,  at  long  inter- 
vals— eight  to  fourteen  days  in  obstinate  cases.  This  theory,  of 
course,  does  not  apply  to  all  forms  of  atonic  constipation,  particu- 
larly those  cases  in  which  the  feces  remain  soft  and  marked  processes 
of  decomposition  (flatulence)  take  place,  for  in  these  cases  muscular 
relaxation  of  the  rectum  and  large  intestine  must  be  assumed. 

Symptoms. — The  symptoms  of  chronic  constipation  are  well 
known.  The  most  characteristic  and  prominent  symptom  is  irregu- 
larity in  the  evacuation  of  the  bowel,  this  act  taking  place  not  daily, 
but  at  intervals  of  two,  three  or  even  more  days,  and  then  only 
with  the  aid  of  strong  abdominal  pressure  on  the  part  of  the  patient. 
The  patients  sometimes  feel  perfectly  well,  notwithstanding  all 
this;  often,  however,  they  experience  a  variety  of  discomforts, 
especially  of  a  nervous  nature.  They  complain  of  headache, 
pressure  in  the  head,  congestion  of  the  head,  loss  of  appetite,  men- 
tal depression,  and  hypochondriasis — all  of  which  are  improved 
when  the  bowels  have  been  evacuated  (see  page  419). 

Disturbances  of  this  kind  are  frequently  associated  with  a  very 
limited  ingestion  of  food — a  fact  which  increases  the  evils,  especially 
when  the  emaciation  is  accompanied  by  ptosis  of  the  abdominal 
organs.  In  this  manner  a  vicious  circle  may  become  established, 
the  origin  of  which  it  is  impossible  to  trace.  Colicky  pains  are 
rare  in  atonic  constipation.    Light,  moderate  and  severe  cases  are 


ATONIC  CONSTIPATION  661 

to  be  differentiated  according  to  the  length  of  the  intervals  between 
the  fecal  evacuations,  the  degree  of  the  subjective  symptoms,  and 
the  manner  in  which  the  bowel  reacts  to  therapeutic  measures. 
In  very  obstinate  and  neglected  cases  fecal  impactions  may  form 
in  the  cecum  and  in  the  hepatic  and  splenic  flexures.  The  hard 
fecal  matter  may  become  firmly  lodged  in  the  recesses  and  in  the 
ampulla  recti  (dyschezia),  so  that  softer  fecal  matter  passes  by 
without  dislocating  it  (Plate  XX,  Fig.  4).  These  fecal  impactions 
occasionally  give  rise  to  symptoms  of  stenosis  and  ileus. 

The  test-diet  stool  of  chronic  constipation  with  perfectly  dry 
feces  is  very  small  in  volume,  consisting  of  various  sized  hard  nodules 
and  lumps  which  are  partially  coated  with  a  thin,  varnish-like, 
shiny  layer  of  rectal  mucus.  Microscopically,  no  food  remnants 
of  any  kind  are  recognized,  not  even  remains  of  cellulose.  Micro- 
scopically, as  compared  with  normal  fecal  matter,  remarkably 
few  food  remnants,  such  as  small  muscle  fragments,  potato  cells, 
fat,  and  minute  remains  of  cellulose,  are  visible.  The  fecal  matter 
is  of  neutral  reaction  and  odorless;  in  the  incubator  no  gases  are 
formed,  and  even  there  its  reaction  remains  unaffected.  In  cases 
in  which  there  is  a  muscular  relaxation  of  the  intestine  and  the 
feces  remain  soft,  the  test-diet  stool  corresponds  to  the  test-diet 
normal  feces  (see  page  133). 

Besides  primary  atonic  constipation  there  are  a  number  of 
secondary  varieties  which  may  supervene  as  a  result  of  gastro- 
intestinal morbid  conditions  or  diseases  of  other  organs.  The  test- 
diet  stool  affords  diagnostic  data  when  the  constipation  is  due  to 
catarrh  of  the  intestine. 

Roentgenograms  after  a  bismuth  meal  or  after  a  large  enema 
of  bismuth  emulsion  will  sometimes  give  valuable  information 
(see  page  146).  We  must  not  depend  too  much  on  these  alone. 
They  are  of  value  only  as  confirmatory  evidence  in  constipation. 
The  Roentgen  fluoroscope  is  more  helpful,  but  in  obstipation  rather 
than  in  constipation. 

Treatment. — Parents  and  educators  should  endeavor  to  supervise 
the  bowel  functions  of  childhood;  to  insist  that  the  stools  be 
punctually  evacuated  by  accustoming  the  child  to  a  fixed  hour 
daily;  and,  in  case  of  necessity,  to  establish  regularity  in  defecation 
by  adequate  dietetic  measures.  Purgatives  are  not  permissible 
in  childhood.  Constipation  is  apt  to  accompany  pregnancy,  long 
rest  in  bed,  infectious  diseases,  and  convalescence  after  surgical 
operations.  In  all  these  conditions  it  is  essential  to  carefully  watch 
the  action  of  the  bowels,  and  to  regulate  them  as  occasion  arises. 

The  aim  of  the  treatment  must  be  to  so  improve  the  constipated 
condition  by  dietetic  measures  as  to  finally  attain  regularity  of 
defecation  with  a  normal  food  supply.  The  diet  in  atonic  consti- 
pation is  fully  explained  in  Chapter  VII  (see  page  182),  in  respect 
to  both  its  nutrient  composition  and  its  aims.    The  assertion  that  it 


662  CHRONIC  CONSTIPATION 

should  be  rich  in  residue  has  in  view  the  desirability  of  making  the 
feces  as  voluminous  and  rich  in  water  as  possible.  The  addition  of 
plenty  of  buttermilk,  one-day  kefir,  or  yoghurt  increases  the 
purgative  effect.  When  there  are  present  simultaneously  gastric 
disturbances,  intestinal  catarrh,  or  other  diseases  (e.  g.,  diabetes), 
the  diet  should  be  adapted  to  such  abnormal  conditions,  always 
bearing  in  mind  the  desirability  of  as  great  a  purgative  effect  as 
possible. 

Bluncel  and  Ulrici  employ  a  wheat  bread  containing  fine  sawdust. 
The  finely  sifted  sawdust  of  beechwood  is  recommended  in  the 
proportion  of  one  ounce  to  one  pound  of  dough.  The  bread  may 
have  as  much  as  10  per  cent,  of  sawdust  without  differing  in  taste 
or  appearance  from  ordinary  bread.  Good  results  were  obtained 
by  the  authors  in  80  cases,  it  being  found  that,  although  the  added 
cellulose  was  not  digested,  it  increased  the  peristaltic  movements 
and  the  amount  of  the  fecal  mass. 

Bran  is  frequently  used  with  good  results  in  chronic  atonic  con- 
stipation. The  proportion  of  tough  cellulose,  dense  woody  fiber, 
in  bran  is  said  to  be  20  per  cent.  On  account  of  this  cellulose 
residue,  the  bran  directly  stimulates  peristalsis  and  forms  sufficient 
bulk  for  the  contracting  intestine  to  push  forward.  The  laxative 
property  of  Graham  bread,  whole  wheat  bread,  and  rye  bread 
depends  upon  the  cellulose  they  contain. 

The  new  theory  of  Schmidt,  Strasburger,  and  Lohrisch,  mentioned 
above,  has  brought  about  a  new  treatment  of  atonic  constipation. 
The  researches  of  Lohrisch  established  the  therapeutic  indication  of 
rendering  the  feces  more  voluminous,  softer  and  more  liquid,  thus 
bringing  into  play  the  physiologic  stimulation  of  peristalsis.  A 
wisely  chosen  dietary  stimulates  peristalsis  both  chemically  and 
mechanically.  Often,  however,  the  dietary  prescriptions  are  not 
effective,  either  because  the  intestine  is  too  much  weakened  or 
because  the  patients  do  not  partake  of  the  diet  in  the  prescribed 
manner.  It  was  therefore  desirable  that  some  agent  should  be  dis- 
covered which  would  fulfil  the  above-mentioned  indications,  that  is 
to  say,  a  substance  voluminous,  rich  in  water,  and  hard  to  digest, 
and  which,  if  possible,  would  retard  the  absorption  of  the  other  con- 
stituents of  the  food,  especially  those  containing  cellulose.  This 
substance  has  been  found  by  Schmidt  in  agar,  as  explained  in 
Chapter  XIV  on  Medication.  Agar  absorbs  and  retains  moisture, 
thus  permanently  increasing  its  own  volume. 

Experiments  made  in  the  laboratory  of  Lafayette  B.  Mendel, 
of  Yale  University,  have  verified  the  findings  of  Schmidt.  "While 
ordinary  carbohydrates  are  utilized  perfectly  in  the  alimentary 
tract  of  man,  a  considerable  number  of  carbohydrates,  such  as 
are  contained  in  certain  seaweeds,  are  not  attacked  by  the  digestive 
enzymes.  Experimenting  with  agar,  Mendel  found  that  the  greater 
part  was  excreted  in  the  feces  unchanged.    As  agar  absorbs  water 


ATONIC  CONSTIPATION  663 

readily  and  retains  it,  and  ;is  it  is  able  to  resist  the  action  of 
intestinal  bacteria  as  well  as  the  enzymes,  its  value  in  the  treat- 
ment of  chronic  constipation  is  apparent.  It  gives  bulk  to  the 
stools  without  introducing  any  objectionable  products  of  decom- 
position. 

Agar  may  be  employed  as  an  adjunct  to  a  diet  rich  in  refuse. 
It  is  usually  administered  dry  and  minutely  cut  up.  In  order  to 
obtain  good  results  it  is  essential  to  take  the  agar  in  large  doses — 
30  to  40  Gm.  (1  to  1^  ounces)  every  day,  regularly.  This  quantity 
is  so  large  in  volume  as  to  almost  preclude  the  possibility  of  its 
being  ingested,  dry  agar  being  very  light  in  weight;  but  even  if  so 
large  a  quantify  were  regularly  taken,  the  purely  mechanical  prop- 
erty of  the  agar  would  not  always  be  sufficient  to  bring  about 
a  movement  of  the  bowels,  since  agar  alone  does  not  augment 
the  processes  of  putrefaction  and  fermentation  in  the  intestine. 
Schmidt  has  removed  this  objection  in  a  very  effective  manner 
by  the  introduction  of  cascara-agar,  sold  under  the  trade  name 
"regulin."  Cascara-agar  consists  of  finely  cut-up  agar  with  the 
addition  of  a  small  quantity  (about  2.5  per  cent.)  of  an  aqueous 
fluidextract  of  cascara  sagrada  from  which  the  bitter  principles 
have  been  removed.  The  cascara  is  present  in  so  small  a  quantity 
that  it  has  no  purgative  action;  it  is  liberated  in  the  intestine, 
where  it  simulates  the  stimulating  effects  of  the  natural  decompo- 
sition products  of  the  intestinal  contents  which  are  lacking  in  atony 
of  the  bowel. 

Agar  is  not  a  purgative,  but  is  to  be  viewed  as  a  means  of 
increasing  the  efficacy  of  a  laxative  diet  rich  in  refuse.  It  does 
not  move  the  bowels  promptly,  but  must  be  taken  regularly,  daily, 
for  a  long  time  and  in  sufficient  doses.  Agar  belongs  to  the  diet 
in  constipation  just  the  same  as  fruits  and  vegetables.  Since  it 
is  harmless,  its  use  may  be  continued  for  months.  It  is  useless 
taken  at  intervals  of  several  days.  In  moderate  or  severe  cases 
of  constipation  cascara-agar  is  given  daily  in  doses  of  one  to  three 
heaping  tablespoonfuls,  best  after  meals,  morning,  noon,  and  night, 
or  only  at  noon  and  night.  As  it  is  as  dry  as  straw,  it  requires 
a  vehicle,  and  for  this  purpose  apple-sauce  and  mashed  potatoes 
have  both  been  found  useful;  it  can  be  intimately  mixed  up  with 
either.  It  may  be  taken  into  the  mouth  dry  and  be  washed  down 
with  some  liquid  without  mastication.  When  the  constipation  is 
somewhat  obstinate,  the  effect  of  cascara-agar  becomes  apparent 
after  a  few  days,  the  stools  being  evacuated  more  easily  than 
usual  and  of  a  softer  consistence.  Until  this  end  is  attained,  it 
may  be  necessary  to  use  an  enema  in  order  to  secure  a  bowel  move- 
ment. When  the  remedy  has  produced  its  effect,  the  quantity  to 
be  taken  should  continue  the  same  for  eight  to  fourteen  days. 
After  that  the  patient  should  gradually  reduce  the  dose,  ascertain- 
ing by  actual  experience  the  quantity  necessary  each  day  to  pro- 


664  CHRONIC  CONSTIPATION 

duce  a  soft  and  easy  evacuation.  This  quantity,  in  the  great 
majority  of  cases,  is  considerably  less  than  the  dose  required  at 
the  start.  Even  in  cases  of  obstinate  constipation  two  tablespoon- 
fuls  a  day  will  frequently  be  found  sufficient;  in  many  cases  much 
less  will  do.  The  quantity  that  is  found  to  be  just  sufficient  for  the 
purpose  may  be  continued  daily  for  months.  The  hopes  entertained 
with  regard  to  cascara-agar  have  been  fully  confirmed.  Agar  is 
also  given  in  biscuits,  being  added  to  the  flour  before  baking.  Each 
biscuit  should  contain  5  grains  of  agar  (see  page  287) . 

While  searching  for  something  which  would  fulfil  the  above- 
mentioned  indications  for  constipation,  and  having  the  idea  that 
a  copious  supply  of  fat  would  necessarily  have  a  stimulating  effect, 
twenty  years  ago  A.  L.  Benedict,  of  Buffalo,  found  that  liquid 
petrolatum  given  by  mouth  rendered  the  feces  comparatively  soft, 
while  lubricating  the  intestinal  mucous  membrane.  Liquid  petro- 
latum is  a  clear,  bland,  neutral  oil  obtained  from  petroleum  after 
the  more  volatile  portions  have  been  removed  by  distillation. 
It  does  not  become  rancid  like  the  vegetable  oils.  Taken  into  the 
stomach,  it  passes  through  the  whole  intestinal  tract  unchanged; 
is  not  digested  by  any  of  the  enzymes;  and  is  thus  able  to  exert 
to  the  full  its  emollient  and  lubricating  action.  It  is  absolutely 
non-irritating — a  safe,  mild  laxative  in  tablespoonful  doses  three 
or  four  times  a  day.  The  oil  can  usually  be  found  in  the  feces 
(see  page  650).  Characteristic  of  the  best  preparations  of  liquid 
petrolatum  for  internal  administration,  absolute  freedom  from  taste 
and  odor  should  be  mentioned;  also  a  sufficiently  high  degree  of 
specific  gravity  to  prevent  premature  passage  through  the  bowel. 

The  "grape  cures"  enjoy  more  or  less  reputation,  and  in  connec- 
tion with  their  employment  certain  health  resorts  are  particularly 
recommended  (Meran,  Bozen,  Montreux,  Durkheim).  The  rule 
is  to  eat  three  to  six  kilos  (six  to  twelve  pounds)  of  grapes  daily, 
the  general  diet  meanwhile  being  rich  in  protein  and  non-irritating 
to  the  bowel.  One  kilo  of  grapes  is  eaten  in  the  morning  an  hour 
before  breakfast,  and  the  remainder  of  the  prescribed  daily  quantity 
an  hour  before  dinner  and  supper  respectively. 

Massage  of  the  abdomen  and  the  intestine  over  the  abdominal 
walls  is  fully  described  in  Chapter  X  on  Massage.  It  is  very 
useful  as  an  aid  to  the  dietetic  treatment.  Parallel  kneading  of 
the  abdomen  with  both  hands  is  of  great  assistance  (Fig.  102).  The 
patient  assumes  the  dorsal  decubitus  on  the  massage  bed;  the  legs 
are  stretched,  slightly  raised  on  a  cushion  in  order  to  relax  the 
tension  of  the  abdominal  wall.  The  physician  stands  at  the  patient's 
right  side,  making  kneading  movements  over  the  anterior  and  lateral 
part  of  the  abdominal  wall  in  transverse  direction;  the  hands  work 
in  opposite  directions — the  right  hand  from  right  to  left,  and  the 
left  hand  from  left  to  right,  and  then  vice  versa.  In  the  transverse 
movements  the  right  hand  gradually  rises  from  the  symphysis  to 


ATONIC  CONSTIPATION 


I  ill.-, 


the  umbilicus,  the  left  moving  from  the  ensiform  process  down  to 
the  umbilicus,  then  both  take  the  opposite  direction.  Swedish 
manipulation,  rectal  massage,  rectal  tampons,  and  electricity  may 
also  be  employed  advantageously  (see  pages  22S-230). 

Abdominal  massage,  calisthenics,  regulated  exercise,  running, 
climbing,  walking,  rowing,  swimming,  riding,  tennis,  golf,  or  any 
other  muscular  exercise  that  seems  advisable  should  be  ordered 
for  the  patient  of  sedentary  habits,  and  it  must  be  urged  on  him 
that  if  the  habit  of  constipation  is  not  cured  the  future  promises 
imperfect  action  of  the  liver,  nervous  irritations,  early  cardio- 
vascular disease,  and  arteriosclerosis. 


Fig.  102. — Parallel  kneading  of  the  abdomen  with  both  hands  for  constipation. 
(Zabludowski-Eiger.) 

Marked  constipation  is  quite  frequently  seen  in  individuals 
who  take  a  great  deal  of  exercise  and  do  much  work.  Boas  has 
called  special  attention  to  the  fact  that  good  results  are  often  to 
be  attained  after  the  "rest"  and  "recumbent"  cures.  Systematic 
home  gymnastics  are  very  useful,  especially  the  exercise  and 
strengthening  of  the  compressor  muscles  of  the  abdomen,  which 
is  accomplished  by  repeatedly  changing  the  posture  from  lying  to 
sitting  without  the  assistance  of  the  arms.  The  posture  during 
defecation  is  likewise  of  great  importance.  The  position  with 
elevated  knees  is  the  one  most  appropriate,  because  with  it  the 
abdominal  pressure  can  be  exerted  most  powerfully. 

Should  gastroenteroptosis  be  present,  the  application  of  a  well 
fitting  abdominal  supporting  bandage  often  brings  about  a  prompt 
evacuation  of  the  bowel.  (See  Chapter  XXX  on  Gastroenterop- 
tosis.) 

Especially  in  cases  of  neurasthenia,  hydrotherapeutic  procedures, 
both  general  and  local,  may  be  employed  which  improve  the  appetite 


666  CHRONIC  CONSTIPATION 

and  the  general  state  of  health.  They  stimulate  peristaltic  move- 
ments when  applied  locally  upon  the  stomach  in  the  form  of  the 
cold  Scotch  douche,  cold  towels,  and  cold  sponge  baths.  The  bene- 
ficial effect  of  the  ether  spray  is  well  known.  Twice  a  day  100  Cc. 
(giij)  of  pure  ether  is  sprayed  on  the  skin  of  the  abdomen.  The 
cold  developed  acts  as  a  strong  stimulant  to  the  abdominal  walls 
and  increases  peristalsis.  The  local  application  of  the  electric 
cold-air  douche  has  recently  been  recommended  (Fig.  103,  page  671). 

Should  these  measures,  with  diet  and  agar,  fail,  the  treatment 
by  enemata  must  be  resorted  to.  This  has  been  fully  described 
in  Chapter  XI.  Generally  speaking,  enemata  are  indicated  in  dys- 
chezia;  the  fecal  mass  lies  in  the  rectum  and  cannot  be  forced  out. 
They  act  by  mechanically  distending  the  rectum.  Preference  is 
to  be  given  to  the  small  "retention  enemata"  and  to  Fleiner's 
oil  enemata  (see  page  223).  In  some  instances  the  "paraffin  cure" 
of  Lipowski  and  carbon  dioxid  or  bile  enemata  may  be  tried  (see 
page  226). 

There  are  no  contra-indications  to  duodenal  lavage  in  the  treat- 
ment of  atonic  and  spastic  constipation.  The  whole  intestinal 
canal  can  be  thoroughly  evacuated  and  a  recovery  brought  about 
by  this  method  of  treatment  (see  page  105). 

Medicinal  treatment  of  chronic  atonic  constipation  becomes 
justifiable  only  when  the  therapeutic  measures  mentioned  fail 
to  cure.  The  medicaments  used  for  this  purpose  have  been  fully 
outlined  on  pages  282  to  288  (Chapter  XIV).  When  prescribing 
purgatives,  however,  it  should  be  the  endeavor  to  secure  results  by 
the  use  of  the  smallest  effective  dose  possible  of  the  mildest  drugs, 
such  as  castor  oil,  cascara  sagrada,  tamarinds,  and  phenolphthalein. 
Attempts  should  constantly  be  made  to  discontinue  the  purgatives 
entirely.  When  catarrh  of  the  stomach  or  intestine  coexists  with 
constipation,  Carlsbad  salt  or  magnesium  oxid  should  be  admin- 
istered. Podophyllin  increases  peristalsis  and  is  at  the  same  time 
a  good  biliary  stimulant. 

Good  results  are  reported  from  yeast,  taken  once  or  twice  a  day, 
according  to  the  number  of  bowel  movements  caused.  The  ordinary 
tin-foil  yeast  cake  works  almost  as  well  as  brewer's  yeast.  The 
amount  administered  should  be  about  five-eighths  to  three-quarters 
of  a  cubic  inch,  dissolved  in  half  a  glass  of  water.  This  dose  should 
be  taken  twice  a  day. 

Mention  has  been  made  in  Chapter  XIV  (Medication)  of  the 
subcutaneous  injection  of  aloin,  apocodein,  eserin,  eumydrin, 
and  atropin.  Magnesium  sulphate  can  be  administered  subcuta- 
neously  in  a  dose  of  0.5  to  5  Cc.  (8  to  80  minims)  of  a  25-per-cent. 
solution.  One  cubic  centimeter  (15  minims)  is  the  average  and  the 
most  effective  dose.  The  injections  can  be  made  in  the  buttock  or 
under  the  skin  of  the  abdomen,  with  the  usual  aseptic  precautions. 
They  are  given  daily  until  regular  evacuations  are  established. 


ATONIC  CONSTIPATION  66*2 

A  yellow  hygroscopic  powder  of  crystalline  appearance  lias 
been  extracted  from  the  hark  of  cascara  sagrada  to  which  the 
trade  name  "peristaltin"  has  been  given.  It  is  readily  soluble  in 
water  and  can  be  given  subcutaneously.  The  contents  of  one  or 
two  ampoules  of  0.5  Gin.  (7|  grains)  each  are  injected  in  the  course 
of  twenty-four  hours.  An  aqueous  extract  of  senna  is  dispensed 
under  the  trade  name  "sennatin."  The  intramuscular  dose  is 
1  to  'A  (Y.  (15  to  45  minims).  The  hypodermic  injection  of  2  to 
4  Cc.  (30  to  GO  minims)  of  pituitary  extract  will  stimulate  the 
atonic  and  distended  bowel  when  other  measures  fail;  it  is  neces- 
sary to  give  larger  doses  than  those  needed  to  promote  uterine 
contraction  in  labor;  the  2-Cc.  dose  may  be  repeated,  if  necessary, 
in  two  or  three  hours. 

An  Italian  method  should  be  mentioned,  the  endermic  administra- 
tion of  croton  oil:  a  mixture  of  6  to  10  drops  of  croton  oil  with  15  to 
20  Cc.  (5iv-v)  of  olive  oil  is  rubbed  into  the  skin.  The  results  are 
said  to  have  been  satisfactory. 

Primary  and  secondary  atonic  constipation  may  be  treated  by 
the  drinking  of  mineral  water.  The  secondary  constipation  that  is 
found  in  connection  with  gastric  and  intestinal  catarrh,  hyper- 
acidity, hemorrhoids,  and  liver  derangement,  is  most  favorably 
influenced  by  these  drinking  cures,  particularly  since  the  treatment 
influences  the  cause,  and  not  merely  the  symptom  constipation 
(see  Chapter  XII). 

The  most  recent  intravenous  remedy  for  stimulating  peristalsis  is 
a  hormone  placed  on  sale  under  the  trade  name  "hormonal."  It 
was  discovered  by  Zuelzer.  Injected  intravenously,  it  induces  strong 
peristalsis.  This  hormone  is  extracted  with  normal  saline  solution 
or  diluted  hydrochloric  acid  from  the  mucous  membrane  of  the 
stomach  of  an  animal  killed  while  the  process  of  gastric  digestion 
is  at  its  height;  the  albumin  of  the  extract  is  removed  by  alcohol. 
Small  amounts  can  also  be  obtained  from  the  proximal  portion 
of  the  mucous  membrane  of  the  duodenum.  This  hormone  is  also 
obtained  from  the  spleen;  the  quantities  contained  in  this  organ 
are  so  large  that  at  present  nearly  all  the  available  supply  for 
therapeutic  use  is  obtained  from  this  source. 

Zuelzer  now  recommends  the  treatment  of  chronic  atonic  con- 
stipation with  intravenous  injections  of  peristalsis  hormone,  40  Cc. 
(3x)  for  adults  and  20  Cc.  (5v)  for  children.  This  is  usually 
followed  by  a  slight  rise  in  temperature  (to  100°  F.),  a  feeling  of 
warmth,  some  lassitude,  and  transient  headache.  No  other  evil 
effects  whatever  have  been  noted  in  consequence  of  these  injec- 
tions. The  action  of  the  remedy  is  often  apparent  after  a  few  hours 
by  the  manifestation  of  increased  peristaltic  activity.  •  The  injec- 
tion is  best  given  in  the  morning.  A  single  injection  is  sufficient 
to  establish  permanent  results.  It  is  advisable  to  follow  the  injec- 
tion with  one  dose  of  castor  oil.  The  latter  serves  as  a  lubricant 
while  the  hormone  induces  the  normal  peristaltic  action. 


668  CHRONIC  CONSTIPATION 

Cleansing,  glycerin,  oil,  paraffin,  carbon  dioxid  and  bile  enemata 
are  valuable  measures  in  all  forms  of  constipation  (see  pages 
220-226). 

Surgical  Treatment. — Inflamed  pericolonic  membranes  forming 
bands  and  adhesions  are  causative  factors  in  chronic  obstipation. 
These  membranes  commonly  cover  the  ascending  colon,  but  may 
also  involve  the  transverse  and  the  descending  colon.  They  can 
usually  be  easily  stripped  off  from  the  intestine,  leaving  a  clean 
smooth  surface.  The  adventitious  membrane  is  frequently  as 
delicate  as  a  spider  web;  Jackson  has  admirably  described  it  in 
detail.    These  cases  always  require  surgical  intervention. 

Stasis  of  the  large  intestine  is  a  condition  found  in  every  case 
of  chronic  obstipation.  Lane  believes  this  stasis  produces  a 
toxemia  which  is  responsible  for  many  general  nervous  and  debili- 
tated conditions.  When  these  cases  have  failed  to  respond  to 
ordinary  treatment,  Lane  treats  them  surgically  by  dividing  con- 
stricting bands  and  adhesions,  straightening  kinks  and  angulations. 
In  a  considerable  number  the  relief  has  been  only  temporary, 
obstruction  recurring  sooner  or  later.  In  such  cases  he  performs 
lateral  anastomosis  between  the  ileum  and  the  sigmoid,  and  later 
divides  the  ileum  completely  and  implants  it  into  the  sigmoid; 
after  this  he  removes  the  cecum  and  entire  colon  together  with 
part  of  the  sigmoid.  In  many  cases  he  is  able  to  relieve  the  toxemia 
and  intestinal  stasis  by  this  procedure.    (See  Chapter  XXXIX.) 

SPASTIC  CONSTIPATION. 

In  spastic  constipation  the  retardation  in  the  evacuation  of  the 
bowel  is  induced  by  a  spasm  (enterospasm)  of  a  few  isolated  loops 
of  the  intestine  (see  page  781).  This  spasm  is  brought  about 
by  an  increased  irritability  of  the  vegetative  nervous  system 
(see  page  387),  which  may  be  due -to  neuropathic  conditions  asso- 
ciated with  diseases  of  the  abdominal  viscera  or  pelvic  organs,  or 
to  vagotonia  or  sympathicotonia  associated  with  neurasthenia  or 
hysteria. 

The  normal  function  of  the  intestine  depends  upon  the  innervation 
supplied  by  the  two  opposing  systems  of  nerves,  the  vagus  acting 
as  the  motor  while  the  splanchnics  are  inhibitory.  In  a  general 
way  we  call  the  two  systems,  which  are  so  "wonderfully  well  bal- 
anced, the  vegetative  nervous  system.  Aside  from  individual  vari- 
ations which  may  take  place  under  normal  conditions,  the  several 
organic  functions  may  undergo  far-reaching  changes  through 
excess  of  tonus  on  the  part  of  one  or  the  other  of  these  sets  of  nerves. 
Every  increased  stimulation  of  the  vagus  exerts  an  increased 
influence  on  the  activity  of  the  muscles  of  the  intestinal  canal. 
Excessive  stimulation,  or  vagotonia,  induces  muscular  spasm  of  the 
small  intestine,  contraction  of  the  colon,  and  other  phenomena. 


SPASTIC  CONSTIPATION  669 

Spasms  of  the  colon  arc  observed  by  means  of  palpation  and 
roentgenographic  examination.  They  occur  most  frequently  at 
the  transverse  colon,  hepatic  and  splenic  flexures;  sigmoid,  rectum, 
and  anus.  Spasm  of  the  large  intestine  is  important  as  the  basis 
of  spastic  constipation,  as  distinguished  from  the  atonic  form. 
The  characteristic  symptoms  of  spastic  constipation  are  delay  in 
the  fecal  discharge,  and  an  intestinal  colic  which  usually  precedes 
the  defecation.  In  such  eases  there  are  various  degrees  of  abdominal 
pain,  with  or  without  meteorism,  which  may  affect  the  entire 
abdomen  or  only  certain  portions  of  the  intestine.  These  pains 
are  often  continuous  for  hours,  and  finally  terminate  with  the 
occurrence  of  defecation,  which  is  often  very  voluminous.  It 
is  frequently  possible  to  palpate  the  tender  contracting  intestinal 
loops,  particularly  those  of  the  descending  colon  and  the  sigmoid 
flexure.  There  is  frequent  desire  for  stool,  with  incomplete  evacua- 
tion. The  dejecta  are  small-calibered,  pencil-  or  ribbon-shaped,  due 
to  spasm  of  the  sphincter.  Spasm  is  associated  with  atony  of  the 
distal  segments  of  the  colon,  and  hypermotility  and  normal  or 
reduced  tonus  of  the  proximal  segments.  Spastic  constipation  was 
once  regarded  as  a  separate  phenomenon,  but  a  more  detailed  study 
of  the  functional  disturbances  of  the  intestine  has  altered  this 
view.  Roentgenographic  examination  has  revealed  an  increased 
physiologic  distribution  of  the  movements  of  the  haustra,  and 
hypermotility  with  disordered  movements  in  the  fecal  current. 
Spastic  constipation  is  not  to  be  understood  as  a  mechanical  obstruc- 
tion to  the  passage  of  the  feces  through  the  intestinal  canal;  if 
it  were  this,  hypertrophy  and  distention  of  the  sections  involved 
would  result.  High-grade  spastic  contraction  constitutes  no  hin- 
drance to  the  forward  movement  of  the  intestinal  contents.  Not 
infrequently  spastic  and  atonic  conditions  of  the  colon  alternate 
or  occur  together,  as  is  evidenced  by  the  fact  that  the  retention  of 
feces  in  the  ascending  colon  is  accompanied  by  excessive  tonus  of 
other  sections,  such  as  spasms  at  the  beginning  of  the  transverse 
colon.  When  functional  constipation  varies  in  form,  passing  from 
one  form  into  another,  the  movements  of  the  colon  presenting 
different  conditions  at  different  times,  it  may  be  that  we  shall 
have  to  unite  these  several  manifestations  into  one  group  as  spastic 
constipation  (Plate  XX,  Fig.  2). 

Spastic  phenomena  of  the  colon,  with  or  without  constipation, 
occur  more  frequently  in  women  than  in  men,  probably  because  of 
social  conditions,  the  nervous  status  in  the  better  situated  classes, 
and  the  causal  relation  between  intestinal  function  and  diseases  of 
the  female  genital  organs.  This  is  the  case  especially  in  pronounced 
neuropathic  individuals  who  are  subject  to  organic  disturbances 
of  the  gastro-intestinal  tract.  In  the  neurasthenic,  functional 
disturbances,  among  them  constipation,  usually  arise  without 
spastic  change  of  the  intestine. 


670  CHRONIC  CONSTIPATION 

The  most  varied  conditions  of  the  stool  coexist  with  spasms  of 
the  colon  and  of  the  rectum,  as  to  form,  consistency,  and  frequency. 
In  spasms  of  the  colon  with  prolonged  haustral  segmentation,  the 
fecal  matter  is  in  the  shape  of  irregular  balls,  while  in  proctospasm 
it  is  cylindrical  or  ribbon-like. 

There  seems  to  be  no  definite  correlation  between  tonic  contrac- 
tion and  constipation;  there  may  be  a  normal  or  a  diarrheic  stool 
or  spastic  diarrhea  in  cases  of  pronounced  spasm  of  the  intestine. 
The  test-diet  stool  in  these  cases  is  quite  normal. 

By  regularly  palpating  the  abdomen  and  by  roentgenologic 
observation,  strongly  contracted  sections  of  the  colon  may  be 
located,  especially  of  the  sigmoid  flexure  and  the  descending  colon. 
It  is  easy  to  distinguish  between  contracted  and  filled  coils  of  the 
intestine  by  examining  the  patient  repeatedly  and  at  various 
times  of  the  day.  The  tonus  of  the  anal  sphincter  shows  the 
presence  of  a  proctospasm,  which  accompanies  spastic  contractions 
of  the  colon.  The  characteristic  physical  sign  of  this  disease  is 
found  upon  exploration  of  the  rectum,  which,  instead  of  being 
filled  with  feces,  as  is  common  in  atonic  constipation,  fits  closely 
around  the  examining  finger  (proctospasm),  almost  like  the  finger 
of  a  glove  (see  page  848). 

A  phenomenon  accompanying  spastic  conditions  of  the  intestine 
and  spastic  constipation  is  colitis  in  various  forms.  Enteritis 
membranacea  (see  Chapter  XXXVI)  may  be  considered  in  this 
connection,  for  it  is  marked  by  spastic,  cord-like  contractions  in 
large  or  small  sections,  especially  of  the  sigmoid  flexure,  which  can 
be  palpated  and  roentgenographically  proved  during  the  colic  as 
well  as  in  the  periods  free  from  attacks  (see  page  146).  Entero- 
colitis leads  to  colic  and  other  spastic  phenomena. 

Treatment. — This  variety  of  chronic  constipation  should  also,  if 
possible,  be  treated  only  by  means  of  dietetic  measures.  The  diet 
should  be  given  with  a  view  to  producing  a  chemical  stimulation. 
The  leading  points  of  such  a  chemically  active  diet  are  elucidated  on 
page  185  (Chapter  VII).    The  following  diet  may  be  given: 

Early  :  Arising  in  the  morning,  \  to  1  kilogram  (1  to  2  pounds)  of  grapes, 

watermelon  or  oranges. 
Beeakfast  :    Sardines  in  oil;  tea  with  milk;  white  bread,  butter  (abundantly), 

honey  or  jam. 
Noon:  No  soup.     Meat;  boiled  vegetables;  stewed  fruit;  egg  with 

fruit  juice;  white  bread,   butter;  honey,  grapes,  oranges, 

dates,  figs ;  one  glass  of  sweet  cider. 
Evening:         Cold  meat  or  bacon;  mashed  vegetables  with  egg;  white  bread, 

butter;  cheese;  grapes;  tea  with  whipped  cream. 
10  p.m.  Grapes  or  fruit  marmalade. 

Large  quantities  of  fat  in  the  shape  of  oil,  butter  and  cream  can 
be  highly  recommended,  and  also  act  beneficially  upon  a  possible 
concomitant  hyperacidity.  The  laxative  diet  may  be  assisted  by 
the  use  of  agar  or  cascara-agar. 


SPASTIC  CONSTIPATION  671 

Mechanical  treatment  is  contra-indicated  in  spastic  constipation. 

The  intestine  must  be  kept  as  quiet  as  possible;  forced  bodily 
exertions  and  gymnastics  are  therefore  to  be  prohibited.  Favorable 
effects  are  often  observed  from  a  food  cure — hyperalimentation 
(see  page  569).  Massage  of  the  abdomen  and  rectum  is  not  per- 
missible. 

In  regard  to  electric  treatment,  weak  galvanism  of  the  abdomen 
may  perhaps  be  allowed.  Sedative  hydrotherapeutic  measures, 
both  general  and  local,  may,  however,  be  used  freely.  Withal, 
the  fundamental  disease,  the  nervous  condition,  should  be  improved. 
In  France  the  application  of  the  electric  hot-air  douche  (Fig.  103) 
to  the  abdomen  is  highly  recommended.  This  douche  acts,  on  the 
one  hand,  by  its  warmth,  which  may  be  raised  to  a  considerable 
height;  on  the  other  hand,  by  its  mechanical  effect,  somewhat  like  a 
very  light  efBeurage. 


Fig.  103. — Hot-  and  cold-air  douche. 

Should  these  measures  be  found  inadequate,  enemata  must  be 
resorted  to.  Fleiner's  oil  cure  is  particularly  advisable  in  cases  of 
spastic  constipation.  For  insertion  into  the  rectum  a  flexible  tube 
is  used  which  is  large  enough  to  allow  of  the  easy  injection  of  the 
oil.  This  is  connected  by  means  of  a  soft -rubber  tube  with  a  syringe 
containing  about  twelve  ounces  of  pure  olive  oil.  The  patient  is 
to  lie  on  his  back,  with  the  pelvis  elevated;  the  tube  is  then  gently 
introduced  into  the  anus,  and  the  oil  is  slowly  and  gradually 
allowed  to  flow.  Usually  twenty  minutes  is  necessary  to  complete 
the  injection.  The  tube  need  not  be  introduced  high  up  into  the 
rectum;  if  the  patient  is  in  proper  position  the  oil  will  be  carried 
up.  Given  with  care,  the  injection  of  the  oil  produces  no  sensation. 
The  patient  may  feel  a  desire  to  pass  gas,  but  there  is  no  pain  if 
good  oil  is  used.  The  injections  are  repeated  daily  for  three  or  four 
days,  then  the  amount  of  oil  is  decreased  to  eight  ounces.  The 
interval  between  injections  may  be  lengthened  as  the  patient  im- 
proves.    At  first  it  may  require  a  few  days  before  the  feces  are 


672  CHRONIC  CONSTIPATION 

entirely  evacuated.  After  this  the  comfort  of  the  patient  is  much 
greater  and  the  evacuations  easier.  The  oil  should  be  given  at 
bedtime,  slightly  warmed,  and  retained  all  night  if  possible.  Later 
it  will  be  found  that  the  injection  of  an  ounce  or  two  at  bedtime 
will  produce  a  satisfactory  movement  of  the  bowels  in  the  morning 
(see  page  223) . 

Purgatives,  likewise  glycerin  enemata  and  glycerin  suppositories, 
are  to  be  strictly  prohibited.  The  antispasmodic  medicaments  are 
preeminently  indicated  in  cases  of  spastic  constipation — as  opium, 
extract  of  belladonna,  atropin,  and  eumydrin;  they  may  be  admin- 
istered by  mouth  or  in  the  form  of  suppositories  (see  page  271). 
The  dose  of  eumydrin  is  20  drops  of  a  0.1-per-cent.  solution  three 
times  a  day.  Belladonna  inhibits  the  vagotonia,  and  in  that  way  is 
valuable  in  the  treatment  of  spastic  constipation.  It  is  also  a 
stimulant  to  peristalsis.  Papaverin  hydrochlorid  relaxes  smooth 
muscle  in  general.  It  is  most  effective  in  spastic  conditions,  while 
it  does  not  interfere  materially  with  the  normal  movements  of  the 
intestine.  Its  toxicity  is  low,  and  neither  tolerance  nor  habituation 
from  its  use  has  been  reported.  It  is  especially  valuable  in  all  kinds 
of  gastric  and  intestinal  spasms  and  in  biliary  colic.  Benzyl  ben- 
zoate  is  equally  efficacious  (see  page  276).  Preparations  of  bromid 
may  be  given  to  quiet  the  nervous  system.  The  reader  is  referred 
to  Chapter  XIV  on  Medication. 

Many  clinicians  have  obtained  good  results  by  dilatation  of  the 
anal  sphincter.  This  may  be  accomplished  by  the  use  of  the  rubber 
dilator  (Figs.  153  and  154),  bougies,  or  the  speculum.  Divulsion 
can  also  be  performed  under  an  anesthetic  (see  pages  838-841) . 

FRAGMENTARY  CONSTIPATION. 

Boas  has  described  this  affection  and  named  it  fragmentary 
evacuation  of  the  feces.  The  patients  have  regular  and  unaided, 
but  incomplete,  movements  of  the  bowels,  with  repeated  desire 
to  defecate.  They  will  endeavor  to  have  a  movement  every  two 
or  three  hours,  and,  notwithstanding  considerable  effort,  are 
able  to  evacuate  each  time  only  a  very  small  quantity.  This  is 
not  followed  by  a  sensation  of  relief,  but,  on  the  contrary,  by 
tenesmus  and  a  feeling  of  fulness  in  the  abdomen.  This  disturb- 
ance in  the  fecal  evacuation  is  particularly  frequent  in  men,  and  is 
due  to  a  relaxation  of  the  lower  sections  of  the  large  intestine, 
perhaps  only  of  the  rectum. 

Treatment. — The  treatment  may  be  gathered  from  what  has  been 
already  said.  It  consists  particularly  in  diet,  with  the  addition 
of  cascara-agar.  When  the  subjective  discomforts  are  urgent 
(tenesmus),  anodynes  must  be  used.  The  relaxation  of  the  rectum 
may  be  corrected,  to  a  considerable  extent  at  least,  by  intrarectal 
faradization  and  massage.     (See  Chapter  XL) 


CHAPTER  XXXVIII. 

CHRONIC  DIARRHEA. 

Gastrogenic  Diarrhea;  Intestinal  Fermentative  Dyspepsia; 
Nervous  Diarrhea. 

For  much  of  our  recently  acquired  knowledge  of  the  cause  and 
treatment  of  chronic  diarrhea  we  are  indebted  to  the  systematic 
examination  of  the  feces,  as  inaugurated  by  Adolf  Schmidt.  In 
the  medical  mind  chronic  diarrhea  was  at  one  time  synonymous 
with  intestinal  catarrh  and  nervous  diarrhea,  but  the  systematic 
examination  of  the  feces  and  the  proper  testing  of  the  activity 
of  the  intestine  has  shown  that  many  other  conditions  must  be 
included  in  the  meaning  of  the  term.  We  are  now  in  a  position 
to  differentiate,  aside  from  the  diarrhea  of  chronic  intestinal  catarrh, 
the  following  forms  of  diarrhea: 
I.  Gastrogenic  Diarrhea. 

II.  Intestinal  Fermentative  Dyspepsia. 

III.  Nervous  Diarrhea. 

GASTROGENIC  DIARRHEA. 

A  large  proportion,  probably  the  majority,  of  all  cases  of  chronic 
diarrhea  are  due  to  disturbances  in  the  gastric  function.  It  has 
been  shown  by  Adolf  Schmidt  that  raw  or  smoked  connective 
tissue  cannot  be  digested  except  by  normal  gastric  juice.  The 
intestine  does  not  share  in  the  digestion  of  such  connective  tissue, 
but  it  does  dissolve  boiled  connective  tissue.  When  patients 
affected  with  subacidity  and  achylia  gastrica  are  fed  with  raw  or 
smoked  connective  tissue,  the  material  reappears  completely  un- 
altered in  the  feces.  If,  therefore,  Schmidt's  test  diet  (page  112)  be 
given  to  a  patient  with  achylia  gastrica  who  shows  no  intestinal  dis- 
turbance whatever,  a  stool  is  obtained  which  differs  from  normal 
feces  only  in  the  fact  that  it  contains  the  connective  tissue  of  the  test- 
diet  meal  in  an  unaltered  condition.  This  finding  characterizes 
99  per  cent,  of  all  cases  of  achylia  and  subacidity;  an  isolated 
exception  is  occasionally  noted.  Some  cases  in  which  the  connec- 
tive tissue  reappears  in  the  stool  have  an  altogether  normal  secretory 
condition  of  the  stomach,  and  others  even  hyperacidity.  Con- 
versely, there  are  cases  of  achylia  in  which  the  stomach  is  capable 
of  digesting  connective  tissue,  as  shown  by  an  examination  of  the 
feces.  These  exceptional  cases  are  difficult  to  explain.  They  seem 
43 


674  CHRONIC  DIARRHEA 

to  show  that  there  may  be  a  disproportion  between  the  hydro- 
chloric acid  secretion  and  the  production  of  pepsin.  It  has  been 
proved  that  deficiency  of  pepsin  may  exist  in  hyperacid  conditions, 
and  that,  on  the  other  hand,  in  spite  of  the  absence  of  hydrochloric 
acid  a  sufficient  quantity  of  pepsin  may  be  present. 

Einhorn  and  Laporte  have  made  a  tabulated  report  on  the  amount 
of  pepsin  found  in  110  cases  of  various  stomach  disorders.  They 
conclude  that  in  cases  where  hydrochloric  acid  is  increased  the 
pepsin  units  remain  the  same.  The  action  of  the  pepsin  is  markedly 
rapid  when  hydrochloric  acid  is  increased.  In  cases  with  diminished 
secretion  of  hydrochloric  acid,  pepsin  production  is  also  less.  In 
cases  of  entire  lack  of  secretion  of  hydrochloric  acid,  pepsin  is 
always  present,  but  possibly  only  a  trace  of  it. 

It  is  perhaps  the  pepsin  which  is  the  absolute  essential  in  the 
digestion  of  connective  tissue.  In  cases  of  hyperacidity  with 
incomplete  digestion  of  connective  tissue,  hypermotility  of  the 
stomach  and  pyloric  insufficiency  must  be  kept  in  mind;  the  stomach 
may  be  unable,  for  want  of  time,  to  digest  the  connective  tissue. 
In  many  cases,  however,  no  cause  can  be  discovered  for  the  reversal 
of  the  rule  stated  by  Schmidt.  It  is  possible  that  a  role  at  present 
unknown  is  played  by  the  altered  conditions  of  the  gastric  juice. 
There  is  no  doubt  that  slight  alterations  in  the  work  performed 
by  the  stomach  are  enough  to  interfere  with  the  digestion  of  con- 
nective tissue. 

The  reappearance  of  macroscopically  recognizable  remains  of  con- 
nective tissue  (see  page  1 19)  in  the  feces  after  the  test  diet  proves 
conclusively  that  the  stomach  has  been  unable  to  perform  its  proper 
work.  The  connective-tissue  test,  therefore,  is  an  exceedingly  fine 
one  for  ascertaining  the  functional  condition  existing  in  the  stomach. 
It  is  a  diagnostic  sign  of  the  presence  or  imminence  of  gastrogenic 
intestinal  disturbances.  The  intestinal  symptoms  may  make 
their  appearance  in  the  form  of  vague  subjective  sensations  or 
momentary  irritations  of  the  bowel  which,  without  the  test  diet, 
would  hardly  be  thought  worthy  of  serious  consideration.  In 
atonic  conditions  of  the  stomach,  with  decomposition  processes 
going  on,  though  there  is  hydrochloric  acid  in  the  gastric  juice,  the 
test  connective  tissue  is  occasionally  found  in  the  feces  undigested. 
In  answering  the  question  tentatively,  "How  is  it  possible  that 
such  disturbances  of  the  stomach  can  lead  to  diarrheic  conditions?" 
it  is  well  enough  to  remember  that  formerly  the  greatest  importance 
was  ascribed  to  the  absence  of  the  antiseptic  action  of  the  gastric 
hydrochloric  acid;  but  this  is  certainly  not  the  only  deciding  point, 
for  the  mechanical  irritation  of  the  undigested  connective  tissue 
on  the  intestinal  mucous  membrane  itself,  especially  when  often 
repeated,  is  apt  to  induce  liquidity  and  frequency  of  fecal  dis- 
charges. On  observing  how  large  quantities  of  connective  tissue 
and  muscle  remnants  (see  page  120)  are  excreted  in  cases  of  achylia, 


GASTR0GEN1C  DIARRHEA  675 

particularly  after  eating  rare  meat,  it  is  easily  understood  that  the 
oft-repeated  transit  of  such  masses  of  connective  tissue-  must  oi 
necessity  greatly  irritate  the  delicate  mucous  membrane.  Of  prob- 
ably greater  importance,  however,  is  the  fact  that  coarse  connective- 
tissue  remnants  constitute  an  ideal  culture  medium  for  all  sorts  of 
bacteria  to  multiply  in  the  stomach.  Putrefactive  and  fermentative 
organisms  are  swept  into  the  intestinal  canal,  where  they  develop 
abundant  colonies,  infecting  the  gut  and  leading  to  disintegrating 
processes.  Gastrogenic  diarrhea  is  probably  most  frequently 
brought  about  in  this  manner,  and  in  such  cases  it  is  by  no  means 
rare  to  find  among  the  bacterial  growths  of  the  feces  long  bacilli, 
sarcinre,  yeast,  and  many  other  specimens  derived  from  the  stomach. 
Furthermore,  it  must  be  considered  that  the  increased  demands 
made  upon  digestion  in  the  small  intestine  when  the  stomach  is 
not  functioning  properly  lead  gradually  to  intestinal  insufficiency. 

Symptoms.— There  is  at  first  an  irregularity  in  the  movement 
of  the  bowels,  followed  by  an  occasional  attack  of  diarrhea,  to  which, 
as  a  rule,  no  particular  attention  is  paid.  The  diarrhea  gradually 
becomes  more  frequent  until  no  solid  feces  are  excreted.  The 
laxness  of  the  bowels  constantly  increases  until  occasionally  the 
gravest  symptoms  of  intestinal  disease  follow  slight  derangements 
of  the  stomach.  The  mucous  membrane  of  the  intestine  is  unable 
to  endure,  for  any  length  of  time,  such  abnormal  conditions.  The 
continuous  irritation  finally  leads  to  inflammation,  resulting  in  a 
secondary  catarrh  of  the  small  intestine,  and  sometimes  also  of  the 
large  intestine  (see  page  644).  This  disease  of  the  intestine  may 
progress  while  the  primary  affection  of  the  stomach  improves, 
until  it  finally  appears  to  be  an  entirely  independent  disease.  For 
this  reason  the  gastrogenic  origin  of  chronic  diarrhea  is  frequently 
entirely  overlooked.  But  examination  of  the  feces  after  the  test 
diet  (see  Chapter  IV)  gives  positive  information;  the  appearance 
of  the  feces  is  not  always  uniform,  but  in  all  cases  of  gastrogenic 
diarrhea  there  will  be  traces  of  undigested  raw  or  smoked  connective 
tissue  after  ingestion  of  this  material  in  the  test  meal.  This  finding 
indicates  that  a  disturbance  of  the  stomach  is  either  present  or 
imminent,  and  an  examination  of  the  stomach  contents  after  an 
Ewald  test  breakfast  will,  in  the  majority  of  the  cases,  be  sufficient 
to  confirm  the  diagnosis. 

Other  findings  in  the  feces  will  vary  according  to  the  gravity  of 
the  affection  of  the  intestinal  mucous  membrane.  We  may  have 
the  signs  of  inflammation,  namely,  mucus,  tendency  of  the  liquid 
stools  to  processes  of  putrefaction  with  the  development  of  odors, 
and,  in  rare  cases,  pure  carbohydrate  fermentation.  Furthermore, 
under  certain  circumstances,  disturbances  in  absorption  may  indi- 
cate the  degree  of  the  coaffection  of  the  mucous  membrane  of  the 
small  intestine.  The  chief  point,  however,  is  the  discovery  of  con- 
nective tissue  in  the  feces  (see  page  134). 


676  CHRONIC  DIARRHEA 

Treatment. — The  treatment  of  gastrogenic  diarrhea  consists  in 
energetically  dealing  with  the  diseased  stomach.  Get  the  stomach 
right,  and  the  intestinal  difficulty,  will  frequently  disappear  without 
further  treatment.  The  success  of  such  therapeutics,  which  in 
most  of  the  eases  consists  in  counteracting  the  deficiency  in  hydro- 
chloric acid,  is  certainly  surprising.  An  endeavor  should  always 
be  made  to  treat  the  stomach  in  obscure  cases  of  chronic  diarrhea 
in  which  direct  examination  of  the  stomach  contents  shows  both 
secretion  and  motility,  but  in  which  the  feces  under  the  test  diet 
point  to  the  stomach  as  the  seat  of  the  disease.  If  the  feces  con- 
tain either  connective  tissue  or  certain  special  bacteria,  of  pre- 
sumably gastric  origin,  a  trial  of  the  stomach  treatment  should 
be  made  at  all  events.  One  clear  indication  is  to  eliminate  rare 
or  smoked  meat  containing  connective  tissue  from  the  diet  of 
patients  suffering  from  either  gastric  or  intestinal  disease.  The 
diet  must  always  be  adapted  to  both  the  gastric  disturbances 
(achylia,  catarrh)  and  the  temporary  condition  of  the  intestine 
(catarrh  of  the  small  or  large  intestine,  irregularities  in  absorption, 
putrefaction,  carbohydrate  fermentation).  A  constipating  diet  is 
always  indicated  (see  page  172).  When  hydrochloric  acid  is  absent 
it  should  be  given  freely  as  a  medicament,  together  with  pepsin 
(see  page  258). 

Owing  to  the  absence  of  hydrochloric  acid  from  the  stomach, 
there  is  no  stimulus  for  the  production  of  pancreatic  juice,  and 
consequently  the  digestion  lacks  this  latter  important  element  also. 
This  explains  the  efficiency  of  hydrochloric  acid  given  to  patients 
with  gastrogenic  diarrhea.  The  acid  cannot  be  given  in  amounts 
sufficient  to  replace  the  missing  gastric  secretion,  but  the  amount 
ingested  is  sufficient  to  start  pancreatic  secretion. 

Examination  of  the  stomach  contents  after  an  Ewald  test 
breakfast  will  decide  whether  the  presence  of  connective  tissue 
in  the  feces  is  due  to  hyperacidity  or  to  achylia.  The  medicinal 
treatment  for  this  functional  derangement  must  be  with  either  the 
acids  or  the  alkalis.  The  best  combination  of  alkalis  in  gastrogenic 
diarrhea  with  hyperacidity  is  the  following : 

Gm.  or  Co. 
fy — Cretae  prseparatae, 

Calcii  carbonatis  praecipitati, 

Calcii  phosphatLs  praecipitati  .      .   aa    30 JO  5j 

Misce. 
Sig. — Teaspoonful  in  half-glass  of  water  immediately  after  meals. 

Bismuth  subnitrate  or  bismuth  subcarbonate  may  be  added  to 
the  above  combination  (see  page  265) . 

For  its  beneficial  action  on  the  mucous  membrane  of  the  intes- 
tine, no  drug  is  so  satisfactory  as  bismuth.  When  an  astringent 
action  is  required,  subgallate  of  bismuth  in  the  dose  of  0.3  to  0.6 
Gm.  (5  to  10  grains)  every  four  hours  can  be  given;  for  a  more 


INTESTINAL  FERMENTATIVE  DYSPEPSIA  077 

stimulating  effect,  the  subnitrate  of  bismuth  in  doses  of  0.6  to  1.3 
Gm.  ( 10  to  20  grains)  three  times  a  day;  as  an  antiseptic,  the  salicy- 
late of  bismuth  in  closes  of  0.3  to  0.0  Gm.  (5  to  10  grains)  every  four 
hours.  The  sedative  action  of  opium,  uzara,  bolus  alba,  tannic 
acid,  and  their  preparations,  has  been  fully  described  on  pages  274 
to  270.  Should  there  be  atony  and  pyloric  insufficiency,  strychnin 
sulphate  should  be  given  in  full  doses  until  the  physiologic  action 
of  the  drug  is  secured  (page  407).  It  is  well  to  begin  with  0.001  Gm. 
( ,,',,  grain)  three  times  a  day  and  increase  the  dose  until  0.003  Gm. 
(yV  grain)  is  being  taken.  Should  there  be  no  twitching  of  the 
muscles,  the  dose  can  be  increased  to  0.006  Gm.  (TV  grain),  and 
gradually  to  0.01  Gm.  (§  grain)  if  necessary.  Gastrogenic  diarrhea 
associated  with  pyloric  insufficiency  responds  quickly  to  the  strych- 
nin treatment,  providing  the  perverted  stomach  function  be  ration- 
ally treated  at  the  same  time.  Strychnin  is  not  contra-indicated  in 
gastrogenic  diarrhea  associated  with  pyloric  insufficiency.  Pfaff 
and  Nelson 'have  observed  the  peristalsis  in  rabbits  and  cats  under 
the  Roentgen  ray  and  when  the  intestine  was  bathed  in  saline  solu- 
tion. They  found  that  mix  vomica  did  not  increase  peristalsis. 
Diarrhea  can  often  be  controlled  by  allaying  the  irritation  of  the 
gastrocolic  reflexes.  This  is  best  accomplished  by  anesthetizing  the 
gastric  mucous  membrane  by  administering  0.008  to  0.015  Gm.  (f 
to  \  grain)  of  cocain  a  quarter  of  an  hour  before  meals  for  three  or 
four  days. 

When  patients  are  anemic,  an  iron  astringent  will  sometimes 
act  favorably  upon  the  diarrhea  and  the  anemia  at  the  same  time. 
The  sulphate  of  iron  in  capsule,  in  a  dose  of  0.2  to  0.25  Gm.  (3  to  4 
grains)  three  times  a  day,  after  meals,  can  be  prescribed. 

Secondary  intestinal  catarrh  is  to  be  treated  appropriately  (see 
Chapter  XXXV).  Regularly  continued  lavage  of  the  stomach 
must  not  be  forgotten,  as  it  is  often  effective  even  in  cases  in  which 
all  other  gastric  treatment  has  been  unsuccessful.  Cases  of  chronic 
diarrhea  of  several  years'  standing  can  often  be  cured  completely 
by  lavage  of  the  stomach. 

INTESTINAL  FERMENTATIVE  DYSPEPSIA. 

A  considerable  number  of  people  are  met  with  who  suffer  from 
frequent  abdominal  pains,  noises  in  the  abdomen  (borborygmi), 
flatulence,  chronic  meteorism  (distention),  disturbances  of  the 
appetite,  general  discomforts,  and  frequent  liquid  or  semisolid  stools 
which  are  evacuated  two  to  four  times  daily.  Notwithstanding 
all  this,  the  patients  do  not  appear  to  be  abnormal.  When,  however, 
they  are  placed  on  a  test  diet,  they  pass  a  stool  which  is  either 
thin  or  semifluid,  yellowish  or  bright  yellow  in  color,  and  large 
in  volume;  it  is  pervaded  with  numerous  small  bubbles  of  gas, 
and  has  an  intensely  sour  odor  even  when  fresh.    When  the  feces 


678  CHRONIC  DIARRHEA 

are  carefully  examined  with  the  unaided  eye,  no  remnants  of  protein 
bodies  are  found;  connective  tissue  and  meat  are  seen  to  be  perfectly 
digested  and  the  quantity  of  fecal  fat  not  at  all  excessive.  On  the 
other  hand,  remnants  of  the  mashed  potatoes  ingested  are  found 
in  huge  amounts,  partly  in  the  shape  of  coarse,  cohering,  sago-like 
particles,  and  partly  in  the  form  of  single  potato  cells.  On  micro- 
scopic examination  after  the  addition  of  concentrated  Lugol  solu- 
tion, it  is  seen  that  the  potato  cells  are  not  broken  up,  and  that 
the  starch  enclosed  in  them  is  present  in  an  unchanged  condition. 
In  addition,  large  numbers  of  loose  starch  granules  are  seen  which 
have  lost  their  cellular  coating  and  which,  on  the  addition  of  iodin, 
become  intensely  blue  in  color.  Besides,  there  are  usually  present 
large  numbers  of  the  iodin  bacteria — mention  of  which  is  made  in 
Chapter  IV  on  Examination  of  the  Feces. 

Normal  red  coloration  of  the  feces  is  shown  by  the  "sublimate 
test"  (Plate  VII,  a).  When  the  feces  are  kept  in  the  incubator 
enormous  quantities  of  gas  are  generated  and  the  previous  slight 
acidity  becomes  marked,  the  feces  emitting  a  penetrating  sour  odor. 
(Plate  VIII,  b.)  Occasionally  the  freshly  passed  stools  are  quite 
normal  in  shape,  and  only  careful  microscopic  and  macroscopic 
inspection  will  excite  suspicion.  Of  all  the  nutrients  ingested,  only 
the  carbohydrates  are  poorly  or  not  at  all  digested.  These  undi- 
gested carbohydrates  are  subjected  to  the  action  of  the  fermenta- 
tive bacteria  (to  which  class  preeminently  belong  the  iodin  bac- 
teria) ;  they  undergo  fermentation,  becoming  strongly  acid,  evolving 
a  great  deal  of  gas,  and  giving  the  stool  a  characteristic  putty 
appearance  (see  page  134). 

This  specific  disease-picture  is  by  no  means  rare,  and  many 
patients  are  met  with  who  have  suffered  for  years  from  these  exceed- 
ingly annoying  symptoms.  In  such  cases  a  single  analysis  of  the 
stool  with  the  test  diet  will  clearly  determine  the  pathologic  con- 
dition. When  fermentation  processes  of  this  kind  persist  for  a 
long  time,  it  is  of  course  possible  that  the  intestinal  mucous  mem- 
brane may  be  greatly  irritated,  and  a  secondary  catarrh  induced 
which  naturally  aggravates  the  disease.  Schmidt  believes  the 
fermentative  dyspepsia  is  caused  by  a  derangement  of  the  secretion 
of  the  small  intestine,  which  is  normally  a  powerful  amylolytic 
ferment,  because  the  other  digestive  secretions  (gastric  juice, 
pancreatic  juice,  and  bile)  perform  their  functions  perfectly.  In 
non-complicated  cases  of  intestinal  fermentative  dyspepsia  no 
signs  of  any  organic  intestinal  disease  have  been  found,  even  on 
postmortem  examination.  There  is  another  explanation,  and 
Schmidt  admits  its  possible  correctness;  it  is  that  the  ferment  in 
the  small  intestine  which  breaks  up  the  cellulose  may  be  absent. 
Lohrisch  has  quite  recently  demonstrated  that  the  existence  of 
such  a  ferment  must  be  assumed  as  an  indisputable  fact.  It  is  quite 
easy  to  understand  that  when  the  ferment  does  not  dissolve  the 


INTESTINAL  FERMENTATIVE   DYSPEPSIA  679 

cellulose  coverings  which  enclose  the  starch  granules  of  the  potato 
cells,  the  starch  necessarily  must  remain  undigested.      Lohrisch 

has  also  been  able  to  demonstrate  that  patients  with  intestinal 
fermentative  dyspepsia  excrete  on  a  test  diet  much  more  cellulose 
than  the  normal  person.  In  confirmation  of  the  view  that  the 
"cellulose  ferment"  is  at  fault,  the  fact  may  be  cited  that  well- 
dextrinated  flour  is  more  fully  used  up  and  considerably  better 
borne  by  this  class  of  patients  than  are  potatoes  (see  page  61). 

Intestinal  fermentative  dyspepsia  is,  no  doubt,  in  many  instances 
a  primary  disease,  due  to  disturbance  of  the  functions  of  the  small 
intestine,  as  stated;  but  it  may  also  occur  secondarily  to  chronic 
catarrh  of  the  small  intestine,  hyperacidity,  achylia,  or  gastrogenic 
diarrhea. 

Treatment. — The  treatment  of  these  conditions,  particularly 
of  the  primary  disease,  is  clearly  indicated  by  the  findings  of  fecal 
examinations,  and  consists  chiefly  of  purely  dietary  measures. 
The  diet  should  be  such  as  to  counteract  the  processes  of  fermen- 
tation; the  details  are  fully  given  on  page  181  (Chapter  VII).  At 
first  a  pure  protein-fat  diet  should  be  maintained,  with  complete 
exclusion  of  carbohydrates,  by  which  at  one  stroke  the  discomforts, 
borborygmi,  flatulence  and  diarrhea  are  removed,  and  the  stools 
immediately  become  firm  in  consistence.  This  having  been  accom- 
plished, well  opened-up  cells  of  carbohydrates,  infant  flours,  dextrin- 
ated  flour,  toast,  zwieback  and  crackers  are  to  be  slowly  added. 
Later,  and  very  gradually,  farinaceous  products  richer  in  flour 
may  be  allowed,  and  then  the  vegetables.  Potatoes  must  be 
prohibited  for  a  long  time,  and  also  all  those  species  of  vegetables 
which  contain  large  proportions  of  starch,  cellulose  and  sugar, 
as  turnips,  carrots  and  celery.  When  the  symptoms  are  more 
acute  it  may  be  necessary  to  initiate  the  treatment  with  rest  in 
bed  and  the  application  of  either  moist  or  dry  heat  to  the  abdomen. 

Irrigation  of  the  intestine  with  normal  saline  and  antiseptic  solu- 
tions may  be  accomplished  by  direct  instillation  into  the  duodenum 
by  means  of  the  duodenal  tube  (see  Chapter  III) . 

Pure  oxygen  has  been  used  as  an  intestinal  antiseptic.  Schmidt 
introduces  as  much  as  2  to  4  liters  of  oxygen  through  an  Einhorn 
duodenal  tube  (Fig.  11).  He  has  found  it  valuable  in  the  treatment 
of  both  pathologic  putrefaction  and  fermentation  of  the  intestinal 
contents.  When  the  gas  is  introduced  slowly  it  never  inconven- 
iences the  patient.  Colic  or  peristaltic  unrest  does  not  occur.  In 
one  or  two  hours  after  its  introduction  odorless  flatus  passes  the 
anus,  showing  that  the  oxygen  has  passed  through  the  whole  length 
of  the  large  intestine.  The  inflation  is  given  at  first  twice  daily 
and,  as  improvement  ensues,  once  a  day  (see  page  105). 

In  secondary  fermentative  dyspepsia  the  fundamental  disease 
of  the  stomach  or  intestine  must  be  treated  in  preference  to  every- 
thing else. 


680  CHRONIC  DIARRHEA 

NERVOUS  DIARRHEA. 

As  already  stated,  systematic  examination  into  the  functional 
activity  of  the  intestine  and  the  composition  of  the  feces  has  ren- 
dered possible  a  sharp  and  accurate  differentiation  between  diar- 
rhea occurring  in  the  course  of  intestinal  catarrh,  that  of  gastric 
origin,  and  that  due  to  fermentative  dyspepsia.  This  methodic 
arrangement  has  essentially  reduced  the  number  of  diarrheic 
varieties  which  were  formerly  included  in  the  class  of  nervous 
diarrheas.  It  is  now  recognized  that  a  large  number  of  cases  of 
so-called  nervous  diarrhea  are  due  to  other  etiologic  factors.  Yet 
there  undoubtedly  exists  a  real  nervous  diarrhea  which  runs  its 
course  without  perceptible  anatomic  lesion  or  functional  derange- 
ment of  the  intestine. 

Two  forms  of  nervous  diarrhea  are  now  recognized — a  psycho- 
genic and  a  reflex  variety.  Mixed  forms  combining  both  of  these 
are  also  described.  In  the  first  variety  the  urgency  for  immediate 
defecation  with  diarrheic  frequency  may  be  induced  by  psychic 
excitement,  psychic  events,  often  even  by  the  mere  contemplation 
of  some  possible  event  that  may  be  either  pleasant  or  disagreeable 
in  character.  The  best  example  of  this  is  the  diarrhea  provoked 
by  fear.  Reflex  diarrhea,  on  the  other  hand,  is  induced  by  bodily 
stimuli.  Many  people  have  an  attack  of  diarrhea  after  partaking 
of  some  special  articles  of  food  or  drink,  or  when  the  food  has  some 
particular  temperature.  In  other,  cases,  again,  affections  of  the 
genito-urinary  tract  and  of  other  organs  play  a  role.  Certain 
irritations  emanating  from  the  skin  may  lead  to  diarrhea.  The 
characteristic  point  about  nervous  diarrhea  is  that  the  psychic 
(mental)  or  bodily  stimuli  which  evoke  the  diarrhea  are  always 
quite  distinct  and  do  not  exceed  a  certain  etiologic  limit;  in  healthy 
individuals  such  stimuli  would  not  be  productive  of  diarrhea. 
The  question  therefore  arises:  What  are  the  special  conditions 
under  which  these  by  no  means  excessive  stimuli  are  liable  to  give 
rise  to  diarrhea?  Like  all  the  other  varieties  of  diarrhea,  so  with 
the  nervous  diarrheas,  they  are  all  dependent  on  a  hypermotility 
of  the  muscle  fibers  of  the  intestine  and  an  increase  in  the  secretion 
of  the  intestinal  juices.  The  irritative  effect  is  probably  due  to 
inaction  of  cells  or  forces  in  the  vegetative  nervous  system  which 
normally  inhibit  the  activity  of  the  muscular  and  glandular  elements 
of  the  intestine.  It  is  possible  that  stimuli  which  normally  pass 
off  without  producing  any  effect  stimulate  both  the  glandular 
and  the  muscular  structures  of  the  intestine  in  cases  of  nervous 
diarrhea.  As,  however,  not  every  kind  of  stimulus  causes  diarrhea 
in  such  patients,  but  only  one  or  several  quite  distinct  stimuli, 
it  follows  that  the  conductility  for  these  special  stimuli  must  be 
quite  specifically  facilitated,  and  this  is  made  possible  by  means 
of  distinct  pathologic  paths  within  the  vegetative  nervous  system 


NERVOUS  DIARRHEA  lis] 

(see  page  387).    This  is,  however,  conjectural,  us  nothing  really 
definite  is  at  present  known  about  these  matters. 

Symptoms. — Clinically,  the  course  taken  by  nervous  diarrhea  is 
such  that  any  age  of  life  may  fall  under  its  pathologic  influence. 
If  nervous  diarrhea  has  occurred  once  only,  induced  by  any  one 
kind  of  mental  or  bodily  irritation,  the  disease,  dating  from  that 
moment,  may  become  chronic,  often  demonstrating  its  presence 
in  a  most  unpleasant  manner.  At  every  recurrence  of  the  particu- 
lar slight  irritation,  symptoms  of  various  kinds  may  make  their 
appearance,  such  as  abnormal  sounds,  painful  sensations  in  the 
abdomen,  and  suddenly  a  liquid  fecal  evacuation.  These  con- 
ditions may  attain  so  aggravated  a  stage  that  the  patient  finds 
it  impossible,  on  account  of  them,  to  leave  home.  It  will  be  readily 
seen  how  many  disappointing  situations,  in  regard  to  both  social 
and  business  affairs,  are  liable  to  be  occasioned  thereby.  The 
victims  of  nervous  diarrhea  frequently  become  confirmed  neuras- 
thenics. A  preexisting  neurasthenia  of  course  predisposes  to  the 
development  of  nervous  diarrhea  (see  page  418). 

Diagnosis. — The  test-diet  stool  in  cases  of  nervous  diarrhea 
resembles  very  closely  the  recent  contents  of  the  small  intestine, 
and  when  freshly  evacuated  does  not  show  any  signs  of  pronounced 
putrefaction  or  fermentation,  neither  does  it  contain  any  mucus. 
Microscopically,  however,  numerous  food  remnants  may  be  seen 
which  have  escaped  digestion  in  consequence  of  the  increased  intes- 
tinal motilitv.  The  stool  never  contains  connective  tissue  (Plate 
VI).    (See  page  134.) 

Apart  from  the  quality  of  the  feces,  the  previous  history  is  of 
great  importance,  frequently  explaining  the  kind  of  irritation  and 
the  slight  intensity  of  it,  and  indicating  the  absence  of  organic 
diseases  of  the  stomach  or  intestine  and  the  existence  of  a  nervous 
temperament. 

Treatment. — A  consideration  of  the  foregoing  statement  makes 
it  apparent  that  the  treatment  of  diarrhea  of  this  kind  with  astrin- 
gents is  both  useless  and  wrong.  On  the  other  hand,  the  principal 
endeavor  should  be  to  treat  the  mind  (psychic).  To  begin  with, 
the  patients  must  be  assured  that  their  digestive  organs  are  anatom- 
ically normal;  pessimistic  moods  must  be  alleviated,  and  the  atten- 
tion should  be  distracted .  from  the  digestive  apparatus.  To  all 
this  should  be  added  a  thorough  hydrotherapeutic  treatment, 
with  the  object  of  influencing  the  entire  organism  rather  than  the 
digestive  organs  alone.  The  full  and  half-baths,  douches  and 
frictions  deserve  particular  consideration.  An  invigorating  general 
treatment  should  be  instituted.  Simultaneously  ferruginous  and 
arsenical  preparations  should  be  prescribed.  Arsenical  mineral 
waters  should  be  systematically  taken.    (See  Chapter  XII.) 

Sojourn  at  climatic  cure  resorts  of  moderate  altitudes  (2000  to 
3000  feet)  is  to  be  highly  recommended. 


682  CHRONIC  DIARRHEA 

No  specialized  rules  can  be  laid  down  for  the  dietary  treatment. 
In  many  cases  it  is  quite  useless  to  order  a  carefully  selected  diet. 
Some  cases  do  well  on  a  diet  poor  in  residue  and  non-irritating 
in  character.  Experimentation  is  absolutely  necessary.  When 
the  previous  history  shows  that  some  particular  article  of  diet 
induces  diarrhea,  this  should  be  avoided.  A  lactovegetable  diet 
is  often  very  beneficial.  A  sudden  total  change  in  the  diet  fre- 
quently produces  surprisingly  good  results.  At  other  times  a 
constipating  diet  is  beneficial  (see  page  172). 

All  these  measures  can  be  followed  up  most  satisfactorily  when 
the  patient  is  able  to  remain  either  at  a  sanatorium  or  in  a  private 
hospital. 

The  treatment  of  the  acute  diarrheic  seizure,  when  the  latter  is 
very  violent  and  accompanied  by  much  pain,  consists  of  rest  in 
bed  and  the  application  of  warmth  to  the  abdomen.  In  such 
cases  it  will  be  found  impossible  to  exclude  opium  entirely  from 
the  list  of  medicines  (see  page  274). 

The  general  systematic  treatment,  as  described  in  Chapter  XIX 
on  Nervous  Dyspepsia,  can  be  applied  here.  In  case  of  enter- 
optosis  the  application  of  a  suitable  bandage  will  give  great  comfort. 
Subcutaneous  injections  of  sea  water  in  doses  of  30  to  100  Cc. 
(gj-iij)  every  other  day  have  a  general  tonic  influence  (page  423). 
The  bromids  and  chloral  in  small  doses  may  be  necessary  to  relieve 
nervous  irritability.  The  glycerophosphates  of  sodium  and  calcium, 
with  lecithin,  have  been  used  with  marked  success.  Menthol  and 
thymol  in  small  doses  have  been  recommended.  The  intramuscular 
injection  of  iron,  0.05  Gm.  (1  grain)  of  ferric  citrate  once  a  day,  is 
indicated  in  anemic  patients.  This  medication  may  be  combined 
with  the  oral  administration  of  glycerophosphate  of  sodium  0.1 
Gm.  (2  grains) .  Cacodylate  of  sodium  can  be  given  subcutaneously 
once  a  day,  in  doses  of  0.05  to0.2  Gm.  (1  to3grains).     (See  page  581.) 

Eppinger  and  von  Noorden  state  that  many  cases  of  nervous 
diarrhea,  and  especially  the  diarrhea  of  Basedow's  disease,  respond 
quickly  to  the  rectal  administration  of  epinephrin.  After  the 
rectum  is  cleansed  with  an  enema,  20  to  30  drops  of  a  1:1000 
solution  of  epinephrin  diluted  with  10  ounces  of  warm  water  are 
injected  into  the  rectum.  No  unpleasant  subjective  symptoms 
have  been  noted. 


CHAPTER  XjXXIX. 

INTESTINAL  TOXEMIA,  INTESTINAL  STASIS,  AND 
ILEAL  REGURGITATION. 

Intestinal  Toxemia. — Intestinal  toxemia  is  a  form  of  blood  poison- 
ing induced  by  the  absorption  of  toxins  or  microorganisms  from  a 
damaged  intestinal  mucous  membrane.  Any  delay  in  the  passage 
of  the  intestinal  contents  through  the  various  segments  of  the 
intestinal  tract  exposes  the  patient  to  the  danger  of  intestinal 
toxemia.  The  main  fault  is  digestive — some  disturbance,  more  or 
less  severe  and  more  or  less  prolonged,  of  the  digestive  processes. 
Of  course  digestion  is  in  the  main  due  to  enzymes,  but  a  small 
part  of  it  is  accomplished  by  bacteria;  certain  parts  of  the  food 
which  resist  the  action  of  enzymes  would  not  be  digested  at  all 
were  it  not  for  the  microorganisms  in  the  intestine.  On  the  other 
hand,  it  should  not  be  overlooked  that  the  work  of  the  intestinal 
bacteria  is  associated  with  the  production  of  toxins  against  which 
normally  the  organism  must  protect  itself.  The  decomposition 
products  of  bacterial  activity  are  not  all  toxic,  but  in  large  amount 
they  may  have  a  decidedly  toxic  effect.  Should  the  protective 
agencies  of  the  organism,  such  as  the  neutralizing  effect  of  the  diges- 
tive juices  upon  the  toxins,  the  antitoxic  power  of  the  hepatic 
cells,  the  detoxicating  effect  of  the  internal  secretions  (thymus, 
thyroid,  adrenals)  and  of  the  epithelium,  the  excretion  of  intestinal 
toxins  by  way  of  the  expiratory  air,  the  urine  and  the  feces — should 
these,  for  any  reason,  fail  to  act  or  act  inadequately,  intestinal 
toxemia  would  result.  Bacteria  and  their  toxins  are  believed  to 
pass  through  the  damaged  mucous  membrane  into  the  wall  of  the 
intestine  and  induce  inflammation,  with  the  formation  of  pericolic 
membranes  (see  page  561),  though  no  conclusive  proof  has  yet  been 
adduced  to  substantiate  this  view. 

Intestinal  Stasis. — The  term  "chronic  intestinal  stasis"  as 
employed  by  Lane  indicates  such  abnormal  delay  in  the  passage  of 
the  intestinal  contents  through  a  portion  or  portions  of  the  gastro- 
intestinal tract  as  to  result  in  the  absorption  into  the  circulation  of 
a  greater  quantity  of  toxic  or  poisonous  materials  than  can  be  dis- 
posed of  by  the  liver  or  other  protective  organs.  He  believes  this 
condition  is  due  to  the  upright  position  of  the  trunk,  which  induces 
a  prolapse  of  the  viscera  (gastroenteroptosis,  see  page  561)  and 
consequent  faulty  drainage.  To  resist  this  displacement,  Nature 
reduplicates    certain    peritoneal    tissues,    which    becomes    firmer 


684         INTESTINAL  TOXEMIA  AND  INTESTINAL  STASIS 

and  firmer  until  distinct  bands  are  formed.  As  a  consequence, 
under  unusual  or  prolonged  tension,  kinking  occurs  (see  page  561). 
The  kinks  occur  at  the  duodenojejunal  juncture,  the  terminus  of 
the  ileum,  in  the  cecal  region,  at  the  hepatic  flexure,  the  splenic 
flexure,  and  the  colon-sigmoid  juncture  (Fig.  89). 

Heal  Regurgitation. — When  the  ileocecal  valve  is  incompetent, 
there  is  a  backflow  of  fecal  matter  from  the  cecum  into  the  ileum. 
This  condition  can  be  easily  diagnosed  by  means  of  the  Roentgen 
ray  (see  Plate  XIX,  Fig.  2).  Much  has  been  written  in  recent 
years  on  this  condition.  Many  normal  persons  have  ileal  regurgi- 
tation; it  does  not.  do  them  the  harm  that  some  authors  would  lead 
us  to  expect.  When  the  condition  is  pathologic,  the  symptoms 
of  intestinal  toxemia  and  intestinal  stasis  are  present.  Surgical 
measures  are  not  necessary;  the  patients  respond  to  the  usual 
treatment  of  chronic  intestinal  stasis  (see  page  783). 

Etiology. — The  factors  which  contribute  to  the  development  of 
intestinal  toxemia  are  manifold.  Even  when  the  condition  of  the 
digestive  juices  is  entirely  normal,  frequent,  large  and  albuminous 
meals  may  be  abnormally  decomposed.  This  danger  is  increased 
if  there  are  secretory  and  motor  disturbances  of  the  stomach  or 
intestine,  as  in  achylia,  gastric  dilatation,  pyloric  stenosis,  gastro- 
enteroptosis  with  kinks,  constipation,  catarrh  of  the  small  and 
large  intestines,  dilatation  of  the  colon,  intestinal  stenosis,  chronic 
appendicitis,  and  parasites.  In  these  cases  nutriment  of  normal 
quality  in  normal  quantity  may  work  harm.  A  further  factor  may 
be  supplied  by  the  weakening  of  the  defenses  of  the  organism, 
through  infectious  diseases,  affections  of  the  intestinal  mucosa, 
hepatic  insufficiency,  anemia,  or  alcohol  (see  page  668). 

Some  authors  believe  that  the  theory  of  a  bacterial  cause  of 
chronic  intestinal  toxemia  is  the  most  plausible.  They  assert 
that  the  colon  bacillus  cannot  do  any  harm  unless  there  is  intestinal 
putrefaction  or  a  denuded  mucous  membrane.  Under  such  con- 
ditions the  colon  bacilli  themselves  become  pathogenic  by  under- 
going a  sort  of  metamorphosis,  with  the  liberation  of  toxins,  the 
absorption  of  which  causes  many  of  the  symptoms  of  chronic 
intestinal  toxemia. 

It  has  recently  been  shown  by  Kendall  that  when  carbohydrates 
are  present  in  the  nutritive  environment  of  most  bacteria,  the 
products  formed  are  chiefly  those  which  arise  from  the  fermenta- 
tion of  the  carbohydrates.  When  utilizable  carbohydrates  are 
not  available,  the  bacteria  must  utilize  the  nitrogenous  constitu- 
ents of  the  medium.  Under  these  conditions,  nitrogenous  waste 
products  become  relatively  large  and  are  more  or  less  toxic.  The 
colon  bacillus  grown  in  sugar-free  nitrogenous  media  will  produce 
indol,  ammonia,  hydrogen  sulphide  and  the  broken-down  protein 
products,  while  if  utilizable  sugars  are  added  to  the  media  the  same 
organism  will  not  produce  any  of  the  products  indicative  of  protein 


/  \  TESTINAL  toxemia  685 

break-down.  Other  microorganisms  will  form  highly  potenl 
toxins  when  they  develop  in  protein  media,  but  form  innocuous 
fermentation  products  when  utilizable  carbohydrates  are  added 
to  the  culture  medium.  It  therefore  seems  logical  to  limit  the 
production  of  these  toxins  by  flooding  the  intestinal  tract  with 
large  quantities  of  suitable  carbohydrates  to  provide  the  neces- 
sary non-nitrogenous  pabulum  for  the  organisms  in  the  intestinal 
canal. 

An  irritation  anywhere  in  the  intestinal  canal  will  impede  the 
circulation  of  blood  at  that  point.  The  neutralizing  alkalis  are 
thus  lessened,  and  the  result  is  a  dry,  inflamed  pathologic  area. 
Here  the  absorption  of  toxins  occurs  which  is  responsible  for  so 
many  symptoms. 

There  seems  now  to  be  little  doubt  that  endemic  goiter  is  due  to 
an  infection.  The  organisms  reach  the  intestinal  tract  through  the 
infected  soil,  water  and  food.  Animal  experimentation  substantiates 
this  view.  It  is  also  possible  that  the  pathogenic  agent  may  be 
one  of  the  various  organisms  or  toxins  harbored  in  the  tonsils, 
or  in  diseased  sinuses  or  teeth  (see  page  290  and  Plate  XXIII). 

Course  of  Intestinal  Toxemia. — Even  in  normal  digestion  aromatic- 
substances  and  ptomains  are  formed  in  the  intestine,  owing  to  the 
action  of  the  bacteria  upon  the  proteins.  These  substances  are 
partly  excreted  in  defecation.  If  the  quantity  increases,  conse- 
quent diarrhea  will  hasten  their  expulsion.  The  residue  will  be 
neutralized  by  the  mucosa,  assimilated,  passed  through  the  liver 
and  taken  up  into  the  circulation,  where  it  will  be  definitely  decom- 
posed by  the  action  of  the  internal  secretions.  The  end-products 
will  then  be  excreted  through  the  skin,  the  lungs,  and  the  kidneys. 
If,  then,  these  products  of  normal  digestion  are  toxic,  the  decom- 
position products  of  abnormal. digestive  processes  must  be  so  to  a 
much  greater  extent.  The  most  toxic  products  are  always  formed 
from  the  proteins,  and  it  is  these  above  all  that  cause  intestinal 
toxemia. 

Metchnikoff  points  out  that  the  secretions  of  the  bacteria  differ 
with  different  food.  If  a  little  fecal  matter  be  placed  in  two  tubes, 
one  of  which  contains  chopped  meat  in  water  and  the  other  chopped 
vegetables  in  water,  the  fluid  in  the  first  tube  after  two  days  becomes 
extremely  poisonous  to  rabbits,  while  the  fluid  in  the  second  is 
entirely  harmless  to  them.  The  bacterial  products  are  thus  differ- 
ent in  the  two  tubes,  although  the  bacteria  are  derived  from  an 
identical  source.  Metchnikoff  reports  his  own  researches  on  the 
bacteria  of  putrefaction  and  their  toxic  products;  in  particular  the 
anaerobes,  Bacillus  putrificus  and  Bacillus  perfringens.  He  has 
demonstrated  that  these  anaerobes  are  a  source  of  toxemia  against 
which  the  organism  must  struggle  with  all  the  means  at  its  dis- 
posal. It  is  during  the  first  few  days  of  the  development  of  these 
putrefaction    anaerobes    that   their   products   are   most    intensely 


686         INTESTINAL  TOXEMIA  AND  INTESTINAL  STASIS 

toxic.  This  is  interesting  in  view  of  the  assertion  so  frequently 
made  that  putrefaction  in  the  intestine  is  only  the  first  stage  of 
a  process  that  continues  outside  the  human  body.  He  shows 
further  the  analogy  between  the  proteolytic  flora  in  the  intestine 
and  putrefaction  in  general,  wherever  encountered,  and  states 
that  this  constitutes  a  new  argument  in  favor  of  the  pathologic 
importance  of  the  bacteria  of  putrefaction  in  the  human  organism. 

Bacterial  Growth. — Probably  the  most  valuable  means  of  deter- 
mining the  amount  of  bacterial  growth  in  the  intestine  consists 
in  directly  weighing  the  bacteria  isolated  from  the  feces  by  the 
method  of  Strasburger.  In  this  method  the  bacteria  are  separated 
from  the  other  solid  constituents  of  the  feces  by  centrifugation. 
From  one-eighth  to  one-fifth  of  the  total  dry  weight  of  the  feces 
is  made  up  of  bacteria,  and  in  conditions  of  intestinal  disease  the 
proportion  may  amount  to  one-third  or  even  more  (see  page  118). 

Indican. — In  the  breaking  up  of  protein  by  the  putrefactive 
process,  a  number  of  substances  which  have  a  toxic  and  injurious 
effect  upon  the  body  are  produced,  and  these  are  absorbed  from  the 
intestine.  They  all  belong  to  what  is  technically  known  as  "the 
aromatic  series."  The  best  known  of  these  are  skatol,  indol,  and 
phenol.  These  aromatic  products  of  intestinal  putrefaction  have 
much  to  do  with  the  production  of  pericolic  membranes,  bands  and 
adhesions  found  in  cases  of  chronic  intestinal  stasis.  They  are 
carried  to  the  liver,  where  they  combine  with  sulphuric  acid, 
and  are  excreted  in  the  urine  as  ethereal  sulphates.  An  excess  of 
ethereal  sulphates  in  the  urine  becomes  thus  the  measure  and  gauge 
of  the  degree  of  existing  intestinal  putrefaction.  Indican  in  the 
urine  has  the  same  significance.  The  indol  is  rapidly  absorbed  from 
the  intestinal  tract  and  carried  by  the  portal  blood  to  the  liver, 
where  it  enters  into  loose  combination  with  liver  cells;  from  this 
combination  it  is  readily  detached,  to  become  united  with  sul- 
phuric acid;  before  becoming  thus  united,  however,  it  is  oxidized 
into  indoxyl  so  that,  when  united,  it  becomes  chemically  a  potas- 
sium salt  known  as  indoxyl  sulphate  of  potassium.  This  substance 
is  much  less  toxic  than  indol,  finds  its  way  into  the  blood,  and  is 
promptly  excreted  in  the  urine  as  indican.  In  early  life  the  pro- 
duction of  indol  in  the  intestine  is  in  general  very  slight;  and  there 
are  some  older  persons  also  who,  even  while  suffering  from  dis- 
orders of  digestion,  do  not  form  indol.  On  the  other  hand,  the 
production  of  considerable  quantities  of  indol  in  the  large  intestine 
is  a  feature  of  many  cases  of  intestinal  putrefaction,  and  in  some 
cases  the  quantity  formed  is  large.  That  indol  may  be  absorbed 
in  considerable  amounts  is  shown  by  the  appearance  of  large 
quantities  of  indican  in  the  urine  of  persons  in  whom  the  intestine 
contains  large  amounts  of  indol   (Herter). 

We  cannot,  however,  depend  upon  the  presence  of  indican  alone 
in  the  diagnosis  of  intestinal  toxemia.     Indican  in  increased  quan- 


TYPES  OF  INTESTINAL  ITT  REFACTION  687 

tities  is  usually  present  in  the  urine  in  acute  and  chronic  gastritis, 
acute  and  chronic  peritonitis,  typhoid  fever,  dysentery,  ileus, 
carcinoma,  cholera,  Addison's  disease,  disease  of  the  central  ner- 
vous system,  empyema,  gangrene  of  the  lung,  and  all  conditions 
where  protein  putrefaction  is  in  progress.  The  finding  of  indie, -m 
in  the  urine  is  not  of  itself  sufficient  to  establish  the  diagnosis,  but 
it  has  some  value  in  connection  with  the  other  signs  of  intestinal 
toxemia. 

Intestinal  toxemia  is  possible  without  indican  and  with  a  perfectly 
healthy  pancreas,  or  at  least  with  one  so  judged  to  be  by  the  com- 
plete digestion  of  nuclear  tissue  (see  page  126).  Those  who  believe 
that  there  can  be  no  intestinal  toxemia  without  indican  in  the 
urine  will  overlook  many  cases.  Cholin  forms  the  base  of  the 
lecithins  which  are  abundantly  present  in  various  animal  struc- 
tures, but  is  in  itself  innocuous;  it  can,  however,  by  the  action  of 
bacteria,-  be  transformed  into  neurin,  which  is  a  highly  toxic  sub- 
stance. Cadaverin  and  putrescin  are  bases  and  products  of  pro- 
tein decomposition. 

Types  of  Intestinal  Putrefaction. — The  variations  in  the  clinical 
manifestations  and  pathologic  accompaniments  of  chronic  intestinal 
putrefaction  suggest  that  the  etiologic  conditions  vary  in  different 
patients,  and  Herter  has  suggested  the  three  following  types: 

1.  The  Indolic  Type,  marked  by  striking  indicanuria  and  prob- 
ably due  to  members  of  the  Bacillus  coli  group. 

2.  The  Saccharobutyric  Type,  which  seems  to  be  initiated  chiefly 
by  the  anaerobic  forms.  In  its  simplest  examples  there  is  very 
little  indol  in  the  gut. 

3.  A  Combined  Type,  or  cases  combining  the  characteristics  of 
groups  1  and  2. 

Indolic  Type. — "In  these  cases  the  members  of  the  B.  coli  group 
form  indol  in  considerable  quantities  and  they  probably  invade 
the  small  intestine  in  large  numbers.  The  bacterial  cleavages 
seem  largely  to  replace  normal  tryptic  digestion." 

Saccharobutyric  Type. — "In  this  type  the  seat  of  the  putre- 
factive process  is  the  large  intestine  and  lower  ileum.  It  is  due  to 
the  activity  of  the  strictly  anaerobic  butyric-acid-producing  bac- 
teria. Although  our  study  is  not  yet  exhausted,  it  may  be  con- 
fidently stated  that  in  many  cases  B.  aerogenes  capsulatus  is  largely 
responsible.  With  this  form  may  be  associated  B.  putrificus  and 
possibly  sometimes  the  bacillus  of  malignant  edema,  although  often 
these  forms  are  not  found  in  cultures  on  any  of  the  ordinary  media. 

"The  abundance  of  putrefactive  anaerobes,  especially  of  B. 
aerogenes  capsulatus,  gives  a  peculiar  character  to  the  intestinal 
contents.  The  organisms  attack  carbohydrates  and  proteins 
vigorously,  and  butyric  acid  is  formed  from  both,  together  at  times 
with  propionic,  caproic  or  valeric  acid.  These  acids  are  largely 
responsible  for  the  odor  of  the  stools.     From  proteins,  besides  these 


INTESTINAL  TOXEMIA  AND  INTESTINAL  STASIS 

acids,  hydrogen,  carbon  dioxid  and  perhaps  methane  are  formed. 
As  a  consequence  the  feces  have  a  low  specific  gravity  and  often  a 
decidedly  light  color.  The  presence  of  hydrogen  leads  to  the 
extensive  reduction  of  bilirubin  and  other  pigments.  The  Schmidt 
test  with  mercury  bichlorid  gives  a  strong  pink  color."  (See  page 
116.)  "The  stools  have  an  acid  reaction,  although  the  acids  are 
neutralized .  in  part  by  ammonia  and  other  bases  formed  in  the 
process  of  putrefaction.  It  is  probable  that  the  ammonium  buty- 
rate  acts  as  an  irritant  to  the  gut,  causing  soft  stools  or  diarrhea. 
Indol  is  absent,  or  present  in  small  amounts.  Phenol  occasionally 
is  found  in  slight  excess.  In  the  urine  the  ethereal  sulphates  at 
times  are  excessive,  although  the  reason  for  this  is  not  clear.  Mer- 
captan  may  be  present  in  the  feces  as  a  trace;  it  also  is  found  in 
cultures  by  means  of  the  isatin-sulphuric-acid  test.  It  has  been 
noted  that  as  the  patient  improves  the  mercaptan  becomes  less  or 
disappears,  but  the  explanation  of  this  phenomenon  is  at  present 
unknown." 

Combined  Indolic  and  Saccharobutyric  Type. — "Examples  of 
this  type  of  intestinal  putrefaction  are  common.  There  are  many 
putrefactive  anaerobes  in  the  gut,  and  also  a  persistent  and  well- 
marked  indicanuria,  which  is  but  slightly  influenced  by  diet.  The 
nervous  symptoms  are  relatively  prominent  and  appear  early: 
emotional  irritability  and  periods  of  mental  depression.  Muscular 
or  mental  activity  soon  induces  marked  fatigue.  Later  the  blood 
disturbances  may  appear.  Although  these  patients  have  intervals 
of  improvement  that  continue  for  months,  on  the  whole  the  general 
tendency  is  downward.  They  become  less  robust  and  recuperate 
less  promptly  from  every  succeeding  attack.  They  may  run  along 
for  ten  to  fifteen  years  in  a  weak  condition,  with  periods  of  slow 
improvement,  and  finally  may  present  the  picture  of  pernicious 
anemia.  In  others  the  nervous  symptoms  increase  and  the  patients 
may  need  treatment  in  a  sanitarium  or  in  an  asylum  for  the  victims 
of  melancholia. 

"These  various  manifestations  in  different  individuals  may 
represent  merely  a  differing  reaction  to  the  same  poison.  Whether 
the  nervous  system  or  the  blood  shall  bear  the  brunt  of  the  attack 
is  determined  by  the  relative  vulnerability  of  these  tissues  in  that 
particular  individual.  It  is  noticed  also  that  under  treatment 
one  group  of  symptoms  may  improve  quite  independently  of  the 
other." 

Symptoms. — The  external  appearance  of  the  patient  may  be  the 
first  indication  of  the  presence  of  intestinal  toxemia.  The  patient 
has  a  sickly  expression,  a  pale  yellowish  complexion,  and  a  morose 
disposition;  forehead  and  cheeks  are  prematurely  wrinkled  and 
have  brownish  spots;  the  lips,  in  comparison  with  the  pale  com- 
plexion, are  very  hyperemic  and  swollen.  The  skin  is  dry  and 
scaly,  the  nails  soft  and  fissured.  The  lumbar  glands  are  very 
painful  and  enlarged.     At  night  there  is  a  tendency  to  perspiration. 


TREATMENT  .  689 

There  arc  also  digestive  symptoms,  such  as  anorexia,  dislike  of 
meat,  and  great  thirst.  The  tongue  has  a  brownish  coat,  the  abdo- 
men is  distended,  and  sometimes  the  liver  is  enlarged,  especially  in 
children.  The  state  of  the  digestive  organs  differs  in  different 
individuals,  depending  upon  the  presence  of  ptosis,  catarrhs,  fer- 
mentation, putrefaction,  constipation,  enteritis  memhranacea,  and 
parasites.  The  intestinal  flora  also  displays  characteristic  signs: 
there  is  a  decrease  of  the  aerobic  and  facultative  anaerobic  bacteria 
and  a  predominance  of  the  strict  anaerobes  (Bacillus  mesentericus 
proteus,  putrificus,  putridus),  which  means  a  flora  of  protein  putre- 
faction. 

The  so-called  gastro-intestinal  crises  may  occur,  in  which  the 
accumulated  enterotoxins  are  suddenly  excreted;  these  cases  are 
characterized  by  salivation,  periodic  vomiting,  and  periodic  diarrhea. 
The  other  organs  likewise  suffer  from  the  influence  of  the  intestinal 
toxins.  There  may  be  cholangitis,  severe  icterus,  and  cardiac  mani- 
festations such  as  angina,  tachycardia,  bradycardia,  arrhythmia, 
cardialgia,  neuroses,  and  lowering  of  the  blood-pressure.  The  lungs 
may  be  involved  in  the  form  of  asthma  and  bronchitis.  Inflam- 
mation of  the  tonsils  is  of  frequent  occurrence.  The  nervous  sys- 
tem is  responsible  for  headache,  migraine,  hyperchlorhydria,  and 
mental  derangement.  Anemia,  even  the  pernicious  form,  is  not 
very  uncommon.  Urine  and  feces  show  the  signs  of  increased  pro- 
tein putrefaction  in  the  intestine  (see  page  121). 

Considering  that  intestinal  toxemia  may,  on  the  one  hand,  be 
the  consequence  of  increased  protein  putrefaction  in  the  intestine, 
and  on  the  other  the  consequence  of  insufficiency  of  the  antitoxic 
action  of  the  various  defensive  organs  on  the  normal  decomposition 
processes,  it  follows  that  the  therapy  must  be  twofold,  with  the 
object  of  decreasing  the  intestinal  protein  putrefaction  to  normal 
or  below,  and  increasing  the  function  of  the  antitoxic  and  excretory 
organs. 

Treatment. — The  intestinal  culture  ground  on  which  the  bacteria 
of  protein  putrefaction  thrive  should  be  changed.  This  is  accom- 
plished : 

1.  By  an  antiseptic  diet. 

2.  By  introducing  antagonistic  bacteria  into  the  canal. 

3.  By  antiseptic  medication. 

Antiseptic  Diet. — In  order  to  change  the  culture  ground  of  the 
noxious  bacteria  in  the  intestine,  it  is  necessary  to  restrict  or  exclude 
among  the  natural  foodstuffs  those  which  favor  the  development 
of  the  putrefactive  bacteria,  and  to  prescribe  an  abundance  of  those 
which  counteract  putrefaction.  The  foods  favoring  putrefaction 
are  those  that  contain  protein:  meat,  fish,  eggs,  and  the  flour  of 
lentils,  peas  and  beans.  Meat  especially  increases  intestinal  putre- 
faction; the  less  fresh  the  meat,  the  stronger  the  decomposition. 
Fish  invite  putrefaction;  egg  albumen  is  less  susceptible,  but  the 
44 


690         INTESTINAL  TOXEMIA  AND  INTESTINAL  STASIS 

legumes  given  with  the  food  increase  protein  putrefaction  in  the 
intestine. 

The  antiseptic  diet  (see  page  174)  in  intestinal  toxemia  should 
consist  of  farinaceous  and  milk  dishes,  since  milk  (see  page  162) 
in  all  forms,  as  well  as  the  carbohydrates  (with  the  exception 
of  legumes),  inhibits  putrefaction.  Milk  is  an  antiseptic  food, 
owing  to  its  high  percentage  of  milk-sugar,  which  liberates  lactic 
acid  and  succinic  acid  through  the  action  in  the  small  intestine  of 
the  Bacillus  coli  communis  and  the  Bacillus  lactis  aerogenes.  These 
acids  are  capable  of  preventing  the  anaerobic  bacteria  of  putre- 
faction in  the  large  intestine  from  decomposing  the  casein  of  milk 
and  the  protein  of  nitrogenous  foods.  But  pure  milk  alone  is  often 
not  well  tolerated,  and  it  is  therefore  advisable  to  use  this  article 
of  diet  in  the  form  of  salicylic  milk  (see  page  176)  or  as  milk  soup 
thickened  with  flour  or  other  material.  The  same  precaution 
should  be  taken  with  skim-milk  (milk  from  which  the  cream  has 
been  removed). 

A  much  greater  effect  on  putrefaction  is  exerted  by  the  various 
products  of  sour  milk.     The  following  may  be  mentioned: 

Whey  (the  clear,  transparent  liquid  residue  expressed  from  milk 
curd  coagulated  with  rennet  or  pepsin)  is  much  used  as  a  hygienic 
beverage  and  a  dietetic  remedy.  Indeed,  special  establishments 
have  been  erected  for  "whey  cures"  in  Baden-Baden,  Creutznach, 
Levico,  Meran,  and  Weisbaden.  In  the  beginning  of  the  treat- 
ment whey  is  sometimes  difficult  to  digest,  but  the  intestine  soon 
becomes  accustomed  to  it.  It  may  first  be  taken  mixed  with  min- 
eral water,  but  later  undiluted,  gradually  increasing  the  daily 
quantity.  It  should  preferably  be  taken  on  an  empty  stomach. 
Whey  can  also  be  used  to  advantage  in  the  preparation  of  soups 
(see  page  164). 

Buttermilk,  owing  to  its  small  protein  and  fat  content  and  its 
high  percentage  of  milk-sugar  and  lactic  acid,  is  well  suited  to  the 
treatment  of  intestinal  toxemia. 

Sour  milk  is  much  better  tolerated  than  fresh  milk,  because  it 
does  not  coagulate  in  the  stomach  and  thus  interfere  with  digestion. 
It  slightly  stimulates  peristalsis  and  diuresis.  Fresh  cheese,  made 
from  either  milk  or  cream,  is  recommended.  Koumiss  and  kefir 
(see  page  164)  are  products  of  the  alcoholic  fermentation  of  milk 
and  are  beneficial. 

Aside  from  milk,  carbohydrates  are  recognized  as  the  best  anti- 
septic foodstuffs.  Among  these  the  best  results  are  obtained  with 
the  various  kinds  of  flour  and  the  baked  foods  made  from  them, 
because,  owing  to  their  tardy  absorption,  they  reach  the  lower 
parts  of  the  intestine,  where  they  gradually  liberate  their  antiseptic 
lactic  and  succinic  acids.  For  this  reason  it  is  wise  to  ingest  with 
every  protein  meal  a  large  quantity  of  farinaceous  food. 

In  intestinal  toxemia  protein  foodstuffs  should  be  restricted  or 


TREATMENT  691 

entirely  excluded.  The  best  article  among  them  is  eggs.  As 
to  fats,  fresh  fat  which  comes  with  the  meat  should  be  avoided, 
while  fresh  butter  is  allowed.  Farinaceous  food  and  milk  products 
arc  to  be  given  in  large  quantities.  Thorough  mastication  is,  of 
course,  ahs  >lutely  necessary.  No  beverages  should  be  taken  with 
the  meals.  It  is  advisable  to  arrange  the  daily  meals  so  that  food 
and  drink  are  taken  alternately  and  not  simultaneously.  After 
every  meal  an  hour's  rest  should  be  taken  in  the  dorsal  or  right 
decubital  position,  without  sleeping. 

In  regard  to  proteins  in  particular,  care  should  be  taken  to  avoid 
those  that  constitute  culture  grounds  for  the  protein  bacteria. 
These  are:  bouillon,  fatty  soups,  roast  meat  gravy,  meat  jelly, 
meat  extract,  tainted  meat,  and  any  meat  which  is  easily  decom- 
posable (venison,  raw  meat,  and  especially  fish).  In  serious  cases 
of  intestinal  toxemia  meats  should  be  absolutely  forbidden,  while 
in  all  cases  those  that  contain  much  purin  should  be  considerably 
restricted.     The  same  is  true  of  the  legumes. 

In  regard  to  farinaceous  food:  raw  or  cooked  fruit  and  vege- 
tables may  be  taken  if  carefully  masticated,  provided  there  is  no 
enteritis;  while  in  the  presence  of  considerable  intestinal  irritation 
(enteritis,  spastic  constipation)  these  coarser  articles  of  diet  should 
be  entirely  forbidden.  The  antiseptic  effect  of  whortleberries  is 
entitled  to  special  mention. 

Antagonistic  Bacteria. — The  bacteria  causing  intestinal  putre- 
faction can  be  attacked  not  only  by  dietary  measures,  but  also  in 
a  direct  way  by  introducing  antagonistic  bacteria  into  the  intestine. 
For  this  purpose  the  lactic-acid-forming  bacteria  or  the  oriental 
Bulgarian  bacillus  are  available.  The  proteolytic  bacteria  may 
produce  their  harmful  effects  in  either  the  small  or  the  large  intes- 
tine; in  the  former  case  the  introduction  of  the  common  lactic 
acid  bacteria  may  reasonably  be  expected  to  be  of  benefit,  since 
the}'  tend  to  localize  themselves  in  the  small  intestine.  If,  how- 
ever, the  proteolytic  process  originates  in  the  large  intestine,  the 
Bulgarian  lactic  acid  bacilli  are  indicated. 

While  the  primary  object  of  introducing  lactic  acid  bacilli  is  to 
inhibit  the  objectionable  activity  of  proteolytic  organisms,  it  is 
possible  that,  in  addition  to  the  formation  of  lactic  acid,  other 
products  associated  with  their  development  may  be  formed  which 
also  act  beneficially. 

The  best  studied  and  the  best  known  of  oriental  curdled  milks 
is  the  Bulgarian  yoghurt  (see  page  164).  This  yoghurt  is  used 
as  a  food  in  Turkey  in  Europe  and  Asia  Minor,  in  Greece  and 
Montenegro,  in  Servia,  Roumania,  and  Bulgaria.  The  yoghurt 
is  prepared  with  a  certain  ferment  called  maya,  which  possesses 
special  properties.  This  maya  has  been  transmitted  and  pre- 
served from  time  immemorial  by  successive  cultures.  Each  day 
the  fresh  milk  is  inoculated  with  part  of   the   preceding   day's 


692         INTESTINAL  TOXEMIA  AND  INTESTINAL  STASIS 

yoghurt,  thus  perpetuating  the  pure  culture.  Yoghurt  is  milk 
concentrated  to  half  its  original  quantity,  the  composition  of 
which,  according  to  Olaf  Jenson,  is: 

Casein 7. 10  per  cent. 

Fats 7.20  per  cent. 

Lactose 8 .  30  to  9 . 4  per  cent. 

Lactic  acid     .      . 0 .  80  per  cent. 

Alcohol 6 .  02  per  cent. 

Yoghurt  is  said  to  have  a  good  effect  in  intestinal  toxemia.  It 
does  not  act  well  in  that  form  of  the  affection  which  is  associated 
with  enteritis  membranacea,  but  in  catarrh  of  the  small  intestine 
it  renders  very  good  service.  It  should  be  taken  either  with  the 
intermediate  meals  (10  a.m.  and  4  p.m.),  or  with  the  principal  meals 
with  farinaceous  dishes,  rice,  pudding,  or  as  a  dessert.  Yoghurt 
may  be  taken  for  months  without  injury.  The  effect  of  the  pure 
niaya  ferments  and  lactobacilli  seems  to  be  weaker. 

Bacillus  acidophilus  is  a  non-motile,  non-pathogenic  bacillus 
found  in  the  feces  of  breast-fed  children  and  in  human  milk.  This 
organism  is  strongly  antiputrefactive  and  is  suitable  for  intestinal 
colonization.  It  has  been  implanted  within  the  intestinal  tract 
instead  of  the  Bacillus  bulgaricus.  Bacillus  acidophilus  has  a 
greater  therapeutic  value  because  it  is  a  normal  inhabitant  of  the 
large  intestine  and  therefore  multiplies  with  greater  rapidity. 

The  addition  of  lactose  and  dextrin  to  a  protein-free  diet  causes 
a  marked  development  of  the  Bacillus  acidophilus  in  the  intestine. 

The  putrefactive  bacteria  can  also  be  attacked  by  the  intro- 
duction of  various  kinds  of  yeast  into  the  intestine.  To  this  end 
beer  yeast  and  wine  yeast  are  utilized.  Beer  yeast  is  best  admin- 
istered by  mouth  with  any  kind  of  liquid,  such  as  sweetened  water, 
alkaline  mineral  water,  or  beer.  Children  are  given  one-half  tea- 
spoonful  two  or  three  times  a  day,  before  meals;  adults  one  tea- 
spoonful  three  times  daily.  The  antiseptic  effect  of  beer  yeast  is 
only  transitory,  and  so  is  that  of  wine  yeast.  The  dose  of  the  latter 
for  adults  is  one  tablespoonful  four  to  six  times  daily,  mixed  with 
water  and  a  half-lump  of  sugar.  The  introduction  of  a  pure  culture 
of  yeast  in  sufficient  quantities  causes  a  rapid  diminution  of  intes- 
tinal putrefaction,  but  this  effect  is  transitory. 

Antiseptic  Medication. — The  putrefactive  bacteria  of  the'  intes- 
tine may  further  be  attacked  by  antiseptic  medication.  There 
is  no  antiseptic  strong  enough,  in  doses  which  would  be  safe,  to 
destroy  the  viability  of  the  bacteria  in  a  quantity  of  fluid  equal  to 
that  contained  in  the  bowel.  For  such  an  effect  Horatio  C.  Wood 
states  that  it  would  require  about  30  Gm.  (1  ounce)  of  phenol  or 
0.3  Gm.  (5  grains)  of  corrosive  sublimate.  On  the  other  hand,  it 
is  theoretically  possible  to  bring  an  antiseptic  influence  to  bear 
in  the  intestine — that  is,  to  restrain  the  development  of  bacteria. 
For  this  purpose,  in  a  quantity  of  culture  medium  equal  to  the  con- 
tents of  the  intestine,  it  would  require:   phenol,  12  Gm.  (3  drams); 


TREATMENT  6*)3 

creosote,  2  Cc.  (30  minims);  formaldehyde  solution,  0.6  Cc.  (10 
minims);  or  betanaphthol,  about  2  Gm.  (30  grains).  These  figures 
do  not  take  into  consideration  the  possibility  of  absorption.  A 
eritieal  examination  of  the  experimental  data  as  to  the  effect  of 
chemical  agents  on  the  intestinal  flora  indicates  that  it  is  possible 
to  reduce  the  number  of  bacteria  in  the  bowel  by  means  of  anti- 
septic agents.  The  evidence  shows  that  the  most  reliable  official 
drug  is  betanaphthol.  It  passes  through  the  stomach  undecomposed 
and  forms  free  naphthol  in  the  intestine,  without  irritation.  Beta- 
naphthol may  be  given  in  large  quantities  and,  as  it  is  slowly 
absorbed,  its  antiseptic  action  lasts  for  a  long  time.  It  may  be 
given  in  doses  of  0.3  to  0.6  Gm.  (5  to  10  grains)  four  times  daily 
(see  page  279). 

Experimental  researches  upon  the  influence  of  hexamethylen- 
amin  upon  intestinal  decomposition  clearly  show  that  the  indican 
in  the  urine  examined  decreases  with  the  daily  administration  of 
hexamethylenamin  and  finally  disappears  altogether.  Hexamethyl- 
enamin  administered  in  daily  doses  of  2  Gm.  (30  grains)  to  a  healthy 
individual,  living  on  a  mixed  diet,  inhibits  ordinary  bacterial  intes- 
tinal putrefaction. 

According  to  Combe,  the  principal  intestinal  antiseptics  are: 
hydrochloric  acid;  menthol,  2  Gm.  (30  grains)  a  day;  bismuth 
salicylate,  0.6  Gm.  (10  grains)  three  times  a  day;  and  ichthyol. 
The  last  named  remedy,  in  the  opinion  of  Rodari,  is  not  sufficiently 
appreciated  as  an  intestinal  antiseptic.  It  is  necessary  to  prescribe 
it  in  large  doses.  Ichthyol  should  be  given  in  capsules,  each  con- 
taining 0.1  Gm.  (2  grains).  Rodari  gives  two  such  capsules  every 
two  hours.  This  may  produce  slight  stomach  symptoms  and 
eructations. 

Chloramine-T  in  doses  of  0.02  to  0.04  Gm.  (|  to  f  grain)  three 
times  daily  will  frequently  give  good  results.  It  is  non-toxic,  is 
well  borne  in  the  intestine,  and  upon  slow  decomposition  in  the  ali- 
mentary tract  effectually  overcomes  the  infectious  condition  and 
deodorizes  foul  stools. 

Calomel,  resorcinol  and  salicylic  acid  may  also  be  mentioned  in 
this  connection. 

Sulphur  sublimatum  is  an  antiseptic  that  can  be  easily  used  in 
intestinal  putrefaction.  Summarizing  the  advantages  of  sulphur 
as  an  intestinal  antiseptic,  Wild  says:  "It  is  almost  tasteless  and 
is  easily  administered;  it  is  insoluble  in  the  stomach,  and  the  greater 
part  of  it  passes  along  the  whole  length  of  the  alimentary  canal; 
it  does  not  interfere  with  the  action  of  any  of  the  digestive  secre- 
tions; it  forms  active  antiseptic  substances  in  the  intestine  when 
their  contents  become  neutral  or  alkaline — some  of  these  sub- 
stances are  gaseous  and  penetrate  to  all  parts  of  the  intestine;  it  is 
sufficiently  non-poisonous  to  be  given  in  effective  doses;  it  has 
valuable  laxative  properties  which  promote  an  early  evacuation 
of  the  intestinal  contents;  and  it  is  cheap." 


694         INTESTINAL  TOXEMIA  AND  INTESTINAL  STASIS 

Putrefactive  bacteria  can  further  be  unfavorably  influenced  by 
the  administration  of  purgatives  (see  page  282)  and  by  intestinal 
irrigations  (see  page  220).  The  principal  laxatives  available  are 
castor  oil,  calomel,  and  the  salines.  Intestinal  irrigation  is  indi- 
cated in  stasis  with  intestinal  toxemia.  Irrigations  with  1-per- 
cent, ichthyol  are  efficacious.  Fleiner's  oil  enemata  (see  page  223) 
have  given  me  better  results  than  any  other  method  of  treatment. 
In  the  stimulation  of  the  antitoxic  organs  the  most  important 
point  is  to  keep  the  kidneys  acting  freely,  in  order  to  hasten  elimi- 
nation. This  is  best  effected  by  duodenal  lavage  and  by  the 
introduction  of  physiologic  salt  solution  by  vein  or  rectum. 

Treating  the  Constipation. — Many  cases  of  chronic  intestinal 
stasis  and  toxemia  recover  when  the  accompanying  constipation  is 
properly  treated.  It  is  of  the  utmost  importance  to  decide  whether 
the  constipation  is  of  the  atonic  or  the  spastic  type.  The  differ- 
entiation is  not  always  easy.  Patients  suffering  from  spastic  con- 
stipation are  vagotonic.  This  can  be  easily  recognized  by  the 
positive  oculocardiac  reflex,  by  Hering's  phenomenon,  and  by  the 
pilocarpin  test  (see  page  390).  Spastic  constipation  is  due  to 
constriction  or  spasm  of  a  few  isolated  loops  of  the  intestine,  read- 
ily demonstrable  by  the  Roentgen  ray.  The  fluoroscope  will  also 
show  the  relaxing  effect  of  a  hypodermic  of  atropin  upon  the  spasm. 
The  enterospasm  may  be  painful  or  not;  in  the  former  case  it  is  due 
to  neuropathic  conditions  associated  with  disease  of  the  abdominal 
viscera  or  pelvic  organs.     (Plate  XX,  Fig.  2.) 

The  aim  of  the  treatment  of  the  atonic  variety  of  constipation 
must  be  to  so  improve  the  muscular  condition  by  dietetic  measures 
as  to  finally  attain  regularity  of  defecation  with  a  normal  supply 
of  food.  The  diet  should  be  large  and  bulky,  rich  in  insoluble 
residue,  including  usually  an  increased  amount  of  carbohydrate, 
and  more  particularly  of  foods  rich  in  cellulose.  These  foods 
increase  peristalsis  by  stimulating  the  muscular  coat  of  the  intestine 
(see  Laxative  Diet,  page  182). 

In  the  treatment  of  the  spastic  variety  of  constipation,  bulky 
foods  are  avoided,  and  a  variety  of  fruits  should  be  given  because 
of  their  chemical  constitution.  They  stimulate  peristalsis,  partly 
because  of  their  fruit  acids,  and  partly  because  they  contain  sugar, 
which  tends  to  increase  the  fermentative  processes  in  the  intestine. 
Easily  melted  fats,  as  well  as  butter,  oil  and  cream,  not  only  have 
a  mechanical  effect,  but  also  act  chemically,  stimulating  peristalsis 
by  means  of  the  great  amount  of  fatty  acids  they  develop.  (See 
Chapter  XXXVII  on  Chronic  Constipation.) 

Petroleum  jelly  will  lubricate  the  whole  gastro-intestinal  tract, 
thus  facilitating  the  passage  of  the  contents.  The  lubrication  of 
the  chyme  in  the  intestine  assists  in  its  timely  removal  in  cases  of 
intestinal  stasis.  After  the  due  administration  of  this  jelly  the 
feces  are  softened  and  under  the  microscope  are  found  to  contain 


TREATMES  T  ('»«.».") 

minute  oil  globules.     Petroleum  jelly  of  the  besl   quality  seems 

tn  ad  quite  as  well  as  the  Russian  mineral  oil  (see  page  582);  it 
is  heavier  and  therefore  mixes  more  thoroughly  with  the  feces;  at 
the  same  time  its  viscosity  prevents  it  from  passing  through  the 
bowel  too  rapidly.  The  jelly,  when  pure,  is  not  absorbed  from  the 
alimentary  tract,  and  even  in  large  doses  has  no  poisonous  effect. 
It  is  useful  not  only  as  a  lubricant,  but  also  as  a  means  of  healing 
superficial  lesions  of  the  mucous  membrane  (see  page  650). 

Lavage. — In  eases  of  intestinal  stasis  associated  with  an  obstruc- 
tion, such  as  kinks,  bands,  membranes  and  adhesions,  I  have  found 
that  duodenal  lavage  (see  page  105)  clears  out  the  whole  of  the 
intestine  above  the  obstruction  and  gives  the  bowel  an  opportunity 
to  recover  tonicity  sufficient  to  effectually  overcome  the  stasis.  If 
there  happen  to  be  adhesions,  compensation  takes  place  in  some 
way  or  other,  and  recovery  is  the  result.  The  kink  may  remain 
the  same,  but  the  patient  recovers  his  health,  which  after  all  is 
the  practical  object  of  any  treatment  in  any  condition.  As  long 
as  normal  motility  is  not  interfered  with,  there  is  absolutely  no 
indication  for  surgical  intervention.  Lavage  restores  normal 
physiology,  and  if  it  is  true  that  the  duodenum  excretes  a  poison 
which  is  responsible  for  a  great  deal  of  the  toxemia  from  which 
patients  suffer,  then  duodenal  lavage  is  the  remedy  to  remove  the 
poison.  I  am  convinced,  from  the  results  obtained  in  the  majority 
of  cases  of  intestinal  stasis,  that  duodenal  lavage  will  do  all  that 
surgery  can  do,  and  do  it  better,  since  it  does  not  entail  a  train  of 
possible  deformities  and  their  consequences. 

Any  of  the  many  duodenal  tubes  can  be  employed  (see  page  99). 
With  a  little  practice  the  tube  can  be  easily  manipulated  to  ensure 
its  arrival  at  the  pylorus,  whence  it  is  carried  by  peristalsis  into 
the  duodenum,  with  the  patient  lying  on  his  right  side.  The 
pylorus  should  be  patulous,  and  it  is  necessary  therefore  to  under- 
take the  proceedings  on  an  empty  stomach.  By  any  of  several 
well-known  tests  (see  page  100)  we  can  ascertain  whether  the  end 
of  the  tube  has  arrived  in  the  duodenum;  and  as  soon  as  it  has, 
lavage  may  be  begun.1 

For  the  treatment  of  intestinal  stasis  in  general,  the  best  solution 
is  30  Gm.  of  magnesium  sulphate  and  30  Gm.  of  sodium  sulphate 
in  a  liter  of  water.  The  lavage  is  given  daily  for  ten  days,  as  a 
first  series  of  applications;  then  on  alternate  days  for  another 
ten  days;  and  the  third  series  follows  at  intervals  of  three  days, 
the  number  of  treatments  given  in  this  last  series  being  only  three 
or  four.  Although  by  this  time  success  is  fairly  certain,  I  have 
made  it  a  practice  to  continue  with  one  lavage  a  week  until  recov- 
ery is  fully  established.  There  are  no  unpleasant  by-effects,  and 
patients  will  tolerate  the  treatment  for  any  length  of  time  without 
discomfort  (see  page  106). 

1  Charles  D.  Aaron,  Treatment  of  Intestinal  Stasis  by  Duodenal  Lavage,  Medical 
Record,  August  17,  1918. 


696         INTESTINAL  TOXEMIA  AND  INTESTINAL  STASIS 

Mechanical  Treatment. — The  mechanical  treatment  consists  prin- 
cipally in  the  use  of  an  abdominal  bandage  which  will  furnish  a 
suitable  support  to  the  relaxed  abdominal  wall.  This  treatment 
acts  beneficially  by  ameliorating  the  symptoms  due  to  tension  or 
stretching  of  the  mesenteries.  For  details  as  to  application  see 
page  574. 

Surgical  Treatment. — Surgery  is  now  frequently  employed  for 
the  cure  of  intestinal  toxemia  associated  with  chronic  intestinal 
stasis.  A  Roentgen-ray  examination  (see  Chapter  V)  with  the 
bismuth  mixture  may  show  a  displaced  stomach,  a  prolapsed  colon, 
kinking  of  the  hepatic  or  splenic  flexure,  spasms  of  different  loops 
of  the  intestine,  or  the  presence  of  bands,  membranes  and  adhesions; 
but  such  conditions  do  not  imply  that  surgery  is  inevitably  neces- 
sary. So  long  as  motility  is  not  interfered  with,  there  is  no  abso- 
lute indication  for  surgical  intervention.  A  transverse  colon  can 
be  displaced  anywhere  from  its  normal  position  down  to  the  sym- 
physis without  interfering  with  motility.  The  cinematograph 
shows  that  such  a  displaced  intestine  can  empty  itself  properly 
even  if  the  angulations  at  the  distal  ileum  and  the  hepatic  and  splenic 
flexures  show  absolute  kinks.  It  has  been  proved  that  stasis  is  not 
due  to  an  abnormal  position  of  the  intestine  (kink,  ptosis,  or  redun- 
dant colon)  so  long  as  there  is  no  actual  mechanical  obstruction. 

Recent  experimental  work  by  Keith1  explains  the  mechanism  of 
intestinal  movements,  and  seems  to  account  for  the  production  of 
intestinal  stasis  upon  a  physiologic  basis.  In  his  histologic  studies 
he  discovered  a  nodal  tissue  (see  page  64)  intermediate  between 
nerve  and  muscle  and  interposed  between  Auerbach's  myenteric 
plexus  and  the  smooth  muscle  of  the  intestinal  wall.  This  inter- 
mediate tissue  possesses  two  distinct  functions:  one,  the  initiation 
and  regulation  of  the  muscular  contractions  in  the  segment  of  the 
intestine  which  it  controls;  the  other,  the  power  of  conducting 
impulses  which  lead  to  the  forward  propulsion  of  the  intestinal 
contents.  Not  only  do  the  demonstrable  physiologic  functions 
of  these  "nodes"  explain  the  normal  movements  of  the  intestine, 
but  it  is  obvious  that  a  perversion  of  the  function  of  any  one  of 
them  is  capable  of  giving  rise  to  an  inhibition  of  the  forward  progress 
of  the  intestinal  contents,  with  resulting  intestinal  stasis.  In  the 
establishment  of  this  as  the  physiologic  explanation  of  the  mechan- 
ism of  the  production  of  intestinal  stasis,  Keith  was  able  to  demon- 
strate the  presence  of  definite  fibrotic  and  degenerative  changes 
in  this  nodal  tissue  in  segments  of  the  intestine  extirpated  for  the 
relief  of  chronic  intestinal  stasis.  From  these  investigations  he 
concludes  that  it  is  improbable  that  mechanical  conditions  or 
derangements  of  sphincteric  action  underlie  the  production  of 
intestinal  stasis,  but  rather  that  the  true  cause  is  the  production 

1  A  New  Theory  of  the  Causation  of  Enterostasis.  The  Lancet,  August  21, 
1915,  p.  375. 


TREATMENT  097 

of  sonic  "block"  or  disorder  in  the  nodal  and  conducting  system 
of  the  intestine  analogous  to  the  heart  block  and  similar  disturbances 
of  eardiae  function.  He  does  not  aeeept  Lane's  "drag,  band  and 
kink"  theory  (see  page  561). 

By  short-circuiting  the  ileal  contents  directly  into  the  sigmoid, 
or  by  the  extirpation  of  the  colon,  Lane  has  succeeded  in  curing 
coincident  pyorrhea  alveolaris,  tuberculosis,  arthritis  deformans, 
nephritis,  cystitis,  pyelitis,  endometritis,  salpingitis,  exophthalmic 
goiter,  skin  disease,  colitis,  endocarditis,  epilepsy,  neurasthenia, 
and  a  host  of  other  diseases.  An  operation  like  that  of  colectomy 
is  an  extensive  and  dangerous  one,  and  seems  hardly  justifiable  in 
the  treatment  of  such  chronic  joint  diseases  as  arthritis  deformans 
or  the  arthritis  of  tuberculosis.  It  is  surprising  and  a  bit  confusing 
to  hear  the  cure  of  so  many  varied  and  unrelated  diseases  attributed 
to  one  remedial  operation.  The  connection  which  is  asserted 
between  chronic  intestinal  stasis  associated  with  intestinal  toxemia 
and  the  many  forms  of  ill-health  which  the  short-circuiting  opera- 
tion is  said  to  cure,  is  not  convincing.  In  view  of  the  radical 
treatment  urged  by  the  followers  of  Lane,  and  the  confidence  placed 
in  its  not  yet  entirely  tested  results,  internists  will  do  well  to  culti- 
vate a  sane  conservatism.  We  are  not  warranted  in  encouraging 
surgeons  to  hazard  the  operation  of  short-circuiting  and  colectomy 
unless  we  have  a  definite  organic  intestinal  obstruction  to  deal  with 
(see  page  008). 


CHAPTER  XL. 
FLATULENCE,  METEORISM,  AND  TYMPANITES. 

Distention  of  the  stomach  or  intestine  with  air  or  gas  is  known 
as  flatulence.  When  the  gas  accumulates  to  such  an  extent  in  the 
intestine  as  to  cause  acute  symptoms,  we  call  it  meteorism.  A 
chronic  condition  of  gas  accumulation  in  the  intestinal  canal  we  call 
tympanites.  Normally  the  intestine  always  contains  a  certain 
amount  of  gas.  A  part  of  this  gas  is  atmospheric  air  which  has 
been  swallowed  with  the  saliva  or  taken  with  the  food.  In  this 
way  a  great  deal  of  oxygen  and  nitrogen  is  introduced  into  the 
stomach  and  intestine.  Oxygen  is  quickly  absorbed  and  is  therefore 
never  found  in  the  lower  intestine. 

Origin  of  Gases. — The  intestinal  gases  consist  for  the  most  part 
of  hydrogen,  nitrogen,  carbon  dioxid,  methane,  ammonia,  sulphu- 
retted hydrogen,  with  very  small  quantities  of  volatile  fatty  acids. 
The  nitrogen  is  derived  from  atmospheric  air  introduced  during 
the  act  of  deglutition.  The  other  gases  are  generated  by  the  de- 
composition of  the  ingested  food  through  the  action  of  the  intestinal 
bacteria.  A  small  percentage  of  all  articles  of  food  (protein,  fat, 
carbohydrate,  cellulose)  is  broken  up  by  bacterial  activity.  Car- 
bon dioxid  is  derived  from  the  fermentation  of  the  carbohydrates, 
a  process  which  yields  also  lactic  acid  and  alcohol;  a  small  portion 
is  due  to  the  fermentation  of  cellulose,  which  splits  up  into  carbon 
dioxid,  methane,  hydrogen,  acetic  and  butyric  acids.  The  decom- 
position of  protein  produces  carbon  dioxid,  hydrogen,  and  ammonia. 
Sulphuretted  hydrogen  is  generated  principally  after  certain  articles 
of  food  containing  sulphur  have  been  eaten,  such  as  onions,  garlic, 
and  horseradish. 

The  smallest  quantity  of  these  gases  is  expelled  by  way  of  the 
anus.  The  greater  part  is  absorbed  and  excreted  with  the  air  during 
respiration.  Carbon  dioxid  is  absorbed  most  readily  and  hydrogen 
most  tardily. 

Flatulence  may  be  defined  as  a  condition  in  which  the  presence  of 
gases  is  disagreeably  apparent,  both  subjectively  and  objectively. 
This  may  occur: 

1.  With  an  abnormally  large  collection  of  gas,  the  evacuation 
of  which  is  impeded. 

2.  With  a  normal  quantity  of  gas,  the  evacuation  of  which  is 
impeded. 

3.  With  overformation  of  gases,  and  interference  with  their 
expulsion,  both  at  the  same  time. 


ORIGI.X  OF  CASKS  l ill! I 

4.  When  the  intestinal  gases  become  objectionable,  even  though 
the  quantity  is  normal  and  expulsion  not  impeded. 

These  various  forms  of  flatulence  must  be  recognized,  in  order 
that  an  accurate  diagnosis  may  be  made  and  proper  treatment 
instituted. 

1.  The  formation  of  abnormally  large  quantities  of  gases  may  be 
brought  about  through  either  the  exogenous  or  the  endogenous 
route. 

Exogenous  Gas. — The  exogenous  introduction  of  intestinal  gases 
takes  place  to  a  slight  extent  during  the  normal  act  of  deglutition, 
but  may  attain  excessive  degree  in  aerophagy  (see  page  401)  and 
with  nervous,  rapid  eaters.  The  flatulence  in  these  patients  is 
characterized  by  the  expulsion  of  large  volumes  of  odorless  gases 
(nitrogen),  although  the  intestinal  functions  are  perfectly  normal, 
and  neither  the  quantity  nor  the  quality  of  the  food  has  any  appre- 
ciable influence  on  the  formation  of  the  gases.  The  feces  do  not 
putrefy  or  ferment  when  kept  in  an  incubator. 

Endogenous  Gas. — The  endogenous  abnormal  formation  of  gases 
is  an  alimentary  one,  i.  e.,  it  is  brought  about  by  decomposition  of 
the  contents  of  the  intestine.  In  occasional  instances  all  articles 
of  food  give  rise  to  increased  formation  of  gases,  especially  when 
the  bacteria  of  decomposition  predominate  in  the  intestinal  tract. 
The  beginning  of  abnormal  decomposition  of  various  kinds  of  food 
is  not  infrequently  in  the  stomach.  When  there  is  achylia  or  motor 
insufficiency,  the  ingested  food  becomes  contaminated  with  the 
organisms  of  putrefaction  and  fermentation.  ^Ye  know  that  micro- 
organisms have  their  habitat  in  the  healthy  as  well  as  in  the  dis- 
eased body,  and  that  the  production  of  gas  is  absolutely  dependent 
upon  their  presence.  The  function  of  hydrochloric  acid  in  the 
stomach  is  to  assist  digestion  and  to  destroy  bacteria,  but  it  is  not 
a  perfect  sterilizer;  it  does  not  destroy  all  the  germs.  Lnder 
normal  conditions  free  hydrochloric  acid  arrests  fermentation,  but 
may  not  altogether  prevent  it. 

Microorganisms. — In  all  degrees  of  lack  in  the  secretion  of  hydro- 
chloric acid  the  food  that  has  been  taken  into  the  stomach  becomes 
to  a  certain  extent  a  medium  for  the  propagation  of  bacteria. 
In  case  abnormal  fermentation  follows,  gas  is  rapidly  formed. 
In  infants  the  gastric  glands  are  not  fully  developed,  and,  with 
fermentation  of  the  food,  fungi  thrive.  A  similar  condition  exists 
in  adults  in  all  degrees  of  catarrh  of  the  stomach.  Fungi  enter  the 
stomach,  multiply  freely,  and  establish  nidi  for  propagation.  Thus 
the  stomach  may  become  the  direct  cause  of  the  gas,  having  allowed 
the  microorganisms  to  pass  on,  unchallenged,  into  the  intestine, 
where  their  multiplication  is  rapid. 

Bacteria  which  have  passed  through  the  stomach  multiply  rapidly 
in  the  duodenum,  and  continue  to  increase  until  they  become 
extremelv  numerous  in  the  large  intestine.     Fermentation  takes 


700  FLATULENCE,  METEORISM  AND  TYMPANITES 

place  in  the  stomach  and  upper  intestine.  Putrefaction  always 
takes  place  in  the  large  intestine.  It  is  estimated  that  an  unclean 
mouth  can  harbor  over  one  billion  bacteria.  These  are  taken  into 
the  stomach  with  the  food  and  here  find  a  medium  for  rapid  propa- 
gation. 

Flatulence  may  result  from  food  decomposition.  The  large  per- 
centage of  blood  remaining  in  meat  explains  many  cases  of  offen- 
sive decomposition  of  protein — a  fact  to  which  Boas  has  directed 
our  attention.  Raw  meat  and  sausage  containing  blood  are  special 
offenders  in  this  respect.  Eggs  often  give  rise  to  the  formation  of 
large  quantities  of  gas,  especially  when  they  are  not  fresh.  Ordi- 
nary milk  also  decomposes  easily,  just  as  kefir  and  yoghurt  do.  Of 
the  carbohydrates,  the  coarser  varieties  are  particularly  liable  to 
decomposition  because  they  contain  a  large  amount  of  cellulose 
with  the  starch  (see  Intestinal  Fermentative  Dyspepsia,  page  677). 
Pure  white  patent  flours  of  various  kinds  are  usually  well  digested. 
Foods  containing  large  quantities  of  cellulose  are  liable  to  induce 
flatulence  as  a  result  of  cellulose  fermentation.  Fats,  instead  of 
being  normally  digested,  may  become  affected  by  bacteria  and 
decompose,  with  the  formation  of  carbon  dioxid  and  hydrogen. 
In  these  alimentary  cases  it  is  often  difficult  to  correctly  determine 
what  component  of  the  food  produces  the  flatulence,  and  it  may 
require  much  time  and  patient  study  to  decide  the  question. 
Meteorism  is  not  always  present  in  this  form  of  flatulence. 

2.  Flatulence  in  consequence  of  impeded  expulsion  of  gases, 
although  the  quantity  may  be  only  normal,  occurs  hi  chronic  con- 
stipation. This  is  especially  apparent  in  cases  of  organic  obstruc- 
tion; that  is,  in  organic  stricture  of  the  intestine.  In  such  cases 
flatulence  is  often  the  very  first  symptom;  it  is  usually  accompanied 
by  meteorism  and  tympanites.  In  every  case  of  chronic  meteorism 
a  careful  examination  should  be  made  for  intestinal  stenosis.  To 
this  class  belongs  the  flatulence  which  occurs  in  heart  disease  from 
disturbance  of  the  circulation  which  supplies  the  abdominal  organs, 
that  due  to  general  arteriosclerosis,  and  to  sclerosis  of  the  abdominal 
vessels.  In  these  conditions  the  flatulence  is  a  result  of  diminished 
absorption  of  gases  by  the  mucous  membrane  of  the  intestine, 
induced  by  disturbances  in  the  circulation.  In  all  these  cases  the 
flatulence  may  be  accompanied  by  colicky  pains  (colika  flatulenta). 

3.  The  disturbances  mentioned  under  "1"  and  "2"  may  become 
combined,  thus  inducing  an  extreme  condition  of  meteorism. 

4.  It  is  not  uncommon  for  nervous  patients  suffering  from  neur- 
asthenia, hysteria  and  hypochondriasis  to  complain  of  flatulence 
when  the  quantity  of  the  gases  does  not  exceed  the  normal  and  there 
is  no  obstruction  to  their  escape. 

Treatment. — A  consideration  of  the  preceding  statements  leads 
to  the  treatment  as  detailed  below.  The  exogenous  flatulence  of 
aerophagy  and  of  rapid  eaters  is  not  to  be  treated  by  dietary  instruc- 


TREATMENT  701 

tions,  hut  by  systematic  physical  and  hydrotherapeutic  measures 
directed  to  the  whole  nervous  system.  A>  aerophagy  (see  page 
401)  is  a  distinctly  nervous  affection,  it  is  necessary  to  educate  the 
patients  to  a  regular  hygienic  method  of  feeding.  These  persons 
must  gradually  learn  to  eat  slowly,  thoroughly  masticate  their 
food,  and  avoid  talking  at  meal  time. 

For  the  past  few  years  it  has  been  generally  admitted  that  flatu- 
lence may  exist  for  a  long  time  without  any  serious  consequences. 
In  most  instances  there  is  no  actual  increase  in  the  fermentation  of 
the  food.  The  frequent  eructation  of  gas,  or  belching,  is  explained 
on  the  theory  that  swallowing  of  air  takes  place  at  frequent  inter- 
vals, almost  unconsciously  (aerophagy),  and  the  patient  instinc- 
tively endeavors  to  get  rid  of  it.  We  should  absolutely  forbid  this 
practice.  Patients  must  be  instructed  to  allow  the  gas  in  the  stom- 
ach to  enter  the  intestine,  where  its  absorption  and  elimination  are 
rapid. 

It  has  been  repeatedly  proved  that  enteric  pressure  favors  the 
rapid  absorption  of  gas.  Whenever  the  existing  pressure  is  lessened 
by  the  frequent  opening  of  the  cardia  and  rectum,  absorption  is 
delayed.  Habit  thus  plays  an  important  part  in  perpetuating  the 
very  condition  which  it  is  intended  to  relieve.  The  digestive  canal 
can  be  trained  to  master  the  gases  by  quick  absorption.  When  the 
attention  is  actively  kept  up  by  some  interesting  or  important 
subject  (also  during  sleep)  the  gases  do  not  escape  from  the  diges- 
tive canal.  It  is  only  in  easy-going  hours,  when  one's  thoughts 
are  turned  to  the  vegetative  functions,  that  the  need  of  passing 
gas  makes  itself  felt.  There  is,  however,  no  necessity  of  imme- 
diately responding  to  this  sensation.  The  patient  should  be 
impressed  with  the  fact  that  no  harm  will  result  from  retaining  the 
gas.  He  should  try  to  keep  back  the  belching  as  well  as  the  passing 
of  flatus  whenever  possible,  instead  of  yielding  to  the  inclination  of 
the  moment. 

Diet. — Conditions  in  alimentary  flatulence  are  quite  different. 
Here  the  diet  should  be  regulated  most  carefully.  The  amount  of 
food  taken  at  one  time  should  never  be  large.  Care  should  be 
taken  to  have  the  food  cut  up  minutely  and  well  masticated,  since 
large  particles  are  poorly  digested  and  prone  to  decompose.  The 
physician  should  be  careful  to  ascertain  from  the  patient  the 
particular  kinds  of  food  which  have  been  found  to  disagree  with 
him  and  to  cause  flatulence.  By  this  means  it  is  often  possible 
to  acquire  valuable  information  as  to  what  articles  of  food  should 
be  excluded  from  the  diet.  Many  times  the  examination  of  the 
feces  after  a  test-diet  (see  page  112)  shows  whether  the  carbohy- 
drates or  the  proteins  should  be  restricted.  Very  often  the  car- 
bohydrates are  at  fault,  and  then  we  should  restrict  the  coarse 
carbohydrates,  as  rye  bread,  vegetables  rich  in  cellulose,  and  pota- 
toes. The  finer  varieties  of  white  flour,  white  flour  pastry,  dextrinated 


702  FLATULENCE,  METEORISM  AND  TYMPANITES 

flours  and  a  pure  protein-fat  diet  should  be  given  for  a  time.  In  all 
cases  of  flatulence,  raw  and  rare  meat  should  be  prohibited  because 
of  the  blood  it  contains;  meat  should  always  be  thoroughly  roasted 
or  boiled.  One  should  be  very  careful  with  eggs,  permitting  the 
use  of  strictly  fresh  ones  only.  It  is  sometimes  necessary  to  elimi- 
nate milk,  kefir,  and  yoghurt,  or  the  milk  must  be  given  with  sali- 
cylic acid.  One  liter  (quart)  of  milk  is  boiled  with  0.2  Gm.  (3 
grains)  of  salicylic  acid.  The  salicylic  acid  is  first  triturated  with 
a  little  milk  in  a  mortar,  and  when  minutely  divided  is  added  to 
the  total  quantity.  Onions,  horseradish,  lettuce,  potatoes,  cab- 
bage, beets,  peas,  beans  and  radishes  are  to  be  forbidden  in  every 
case.  It  is,  however,  frequently  difficult  to  find  the  proper  diet 
for  each  individual  case;  great  patience  is  necessary.  The  incubator 
test  (see  page  116)  should  be  employed  to  determine  whether  the 
gas  is  due  to  putrefaction  (of  proteins)  or  fermentation  (of  carbo- 
hydrates). If  the  gas  is  due  to  putrefaction,  an  antiputrefactive 
diet  (see  page  174)  is  indicated;  if  to  fermentation,  an  antifermen- 
tative  diet  (see  page  181).  It  should  be  remembered  that  the 
odor  of  the  gas  in  putrefaction  is  always  fetid,  while  there  is  little 
or  no  odor  to  the  gas  of  fermentation.  This  point  is  of  great  value 
in  outlining  the  diet,  especially  when  the  incubator  test  is  not 
available.  Artificial  and  natural  mineral  waters  containing  carbon 
dioxid  gas  are  to  be  forbidden.  Should  constipation  be  a  feature 
of  the  case,  it  should  receive  proper  treatment  (see  page  659). 

Massage. — Abdominal  massage  (effleurage)  will  often  be  found 
very  useful  in  such  cases  by  mechanically  forcing  out  the  gases  (see 
page  211).  The  use  of  a  cannon  ball  (weighing  two  to  five  pounds) 
has  been  found  very  valuable;  the  ball  should  be  rolled  over  the 
large  intestine,  beginning  with  the  cecum,  for  five  minutes  every 
night,  and  the  treatment  continued  for  some  little  time. 

Medication. — An  important  place  was  formerly  held  by  medi- 
cation in  the  treatment  of  flatulence.  Great  virtue  was  ascribed 
to  the  various  teas  (valerian,  peppermint,  caraway,  fennel),  to  the 
ethereal  oils  (oil  of  peppermint,  oil  of  anise,  oil  of  fennel),  and  to 
wood  charcoal  (carbo  ligni).  At  present  we  are  in  a  position  to 
deny  that  these  products  possess  any  curative  properties  whatever. 
If  patients  praise  them,  their  praise  can  refer  only  to  the  agreeable 
carminative  sensation  they  produce  for  a  moment.  Particularly  of 
wood  charcoal  we  know  that  it  is  able  to  exert  its  antiseptic  and 
absorbing  powers  only  when  dry.  There  is  no  medicament  avail- 
able that  will  prevent  the  formation  of  gas  in  the  intestine.  All 
drugs  employed  to  prevent  decomposition  of  the  intestinal  contents 
have  thus  far  failed.  The  absorption  of  gases  by  medicine  is  an 
illusion.  A  diminution  in  the  processes  of  decomposition  in  the 
intestine  can  only  be  expected  from  antiseptic  agents.  Of  these 
the  best  is  salicylic  acid>  particularly  in  the  form  of  magnesium 
salicylate,  1  or  2  Gm.  (15  to  30  grains)  three  times  a  day.    Mag- 


TREATMENT  703 

aesium  salicylate  has  the  valuable  property  <>l'  not  inducing  con- 
stipation. When  the  bowels  arc  lax,  bismuth  salicylate  should  be 
given  because  of  its  astringent  effect. 

For  lactic  acid  fermentation,  ammonium   fluorid   (a   substance 

employed  as  an  antil'erment  in  breweries  and  distilleries)  in  solution 
may  be  given  as  follows: 

Gm.  or  Co. 

1$ — Ammonii  fluoridi 0.2-015  gr.  iij-viiss 

AquaMlestillutu' 300  0  5x 

Misce. 

Sig. — Tablespoonful  after  meals. 

Sulphur  iodid  in  doses  of  0.1  Gm.  (1|  grains)  in  a  capsule  is  an 
effective  remedy  for  the  fermentation  which  accompanies  flatu- 
lence, with  periodical  eructation  of  gas  produced  in  the  stomach, 
as  distinguished  from  that  due  to  air-swallowing  (which  is  almost 
continuous,  and  for  which  the  remedy  named  is  of  no  avail).  Pre- 
cipitated sulphur  checks  lactic  acid  fermentation  and  stimulates 
intestinal  contractions;  it  should  be  given  in  a  dose  of  1  Gm.  (15 
grains)  mixed  with  an  equal  amount  of  calcined  magnesia,  after 
each  meal. 

Physostigmin  is  warmly  advocated  for  the  expulsion  of  gases. 
The  salicylate  should  be  given  according  to  the  following  formula: 

Gm.  or  Cc. 
1^ — Physostigminse  salicylatis  .      .     0.003-0.005  gr,  ^l>-,\, 

Extracti  gentianae,  q.  s. 
Misce  et  ft.  pil.  no.  x. 
Sig. — One  pill  two  or  three  times  a  day. 

Severe  meteorism  following  operation  is  often  relieved  by  the 
hypodermic  injection  of  physostigmin  salicylate  in  doses  of  0.001 
Gm.  (eV  grain)  The  drug  is  well  borne,  even  by  patients  wrho 
are  much  weakened.  The  use  of  physostigmin  is  especially  recom- 
mended in  cases  of  postoperative  paresis  of  the  intestine,  the 
so-called  pseudo-ileus.  The  hypodermic  or  intravenous  injection  of 
pituitary  extract  will  stimulate  peristalsis  and  eliminate  flatus. 
It  is  necessary  to  give  it  in  larger  doses  than  those  employed  for 
stimulating  uterine  contractions  in  inertia  uteri.  A  dose  of  2 
Cc.  (30  minims)  may  be  given,  and  repeated  at  hourly  intervals 
until  three  or  four  doses  are  given  if  necessary.  Hormonal  also 
induces  strong  peristalsis  and  the  passage  of  flatus  (see  page  667) ; 
it  should  be  given  intravenously. 

In  very  obstinate  cases  chronic  flatulence  may  be  treated  by 
means  of  intestinal  tubes.  With  the  patient  recumbent,  an  intes- 
tinal tube  is  introduced  a  few  inches  beyond  the  sphincter  up  into 
the  rectum,  and  left  there  for  an  hour,  perhaps  several  hours.  The 
best  instruments  for  this  purpose  are  stiff  rectal  tubes  of  hard  rub- 
ber with  a  wide  opening  which  does  not  become  readily  obstructed. 
(Soft  tubes  are  liable  to  kink,  thus  becoming  blocked.)     In  this 


704  FLATULENCE,  METEORISM  AND  TYMPANITES 

manner  it  is  sometimes  possible  to  facilitate  the  escape  of  large 
volumes  of  gas.  (See  Chapter  XL)  Enemata,  especially  of 
turpentine,  are  frequently  very  effectual.  The  Noble  formula  is 
particularly  valuable  (see  page  752).  Cold  water  is  often  more 
likely  to  stimulate  peristalsis  than  warm  water. 

When  the  accumulation  of  gas  is  due  to  a  stricture  of  the  intes- 
tine, it  may  be  necessary  to  administer  purgatives  to  diminish  or 
inhibit  the  gas  accumulation.  Only  the  milder  ones  are  to  be 
employed — for  instance,  small  doses  of  castor  oil,  or  the  saline 
cathartic  waters.  The  diet  must  be  regulated  at  the  same  time. 
(See  Chapter  XLVII.) 

When  flatulence  supervenes  in  consequence  of  cardiac  disease  or 
arteriosclerosis,  these  etiologic  diseases  should  receive  careful  atten- 
tion. Systematic  massage  is  frequently  of  benefit,  the  absorption 
of  the  gases  being  favored  by  the  outflow  of  the  venous  blood  induced 
by  it. 


CHAPTER  X LI. 

ULCERS  OF  THE  INTESTINE. 

Duodenal  Ulcer — Ulcus  Rotundum  Duodeni — Peptic  Ulcer 
of  the  Duodenum;  Jejunal  LTlcer. 

DUODENAL  ULCER. 

Duodenal  ulcer  implies  a  disintegration  and  necrosis  of  tissue 
in  the  duodenum.  It  may  consist  of  unhealthy  granulations 
becoming  necrotic  and  gangrenous.  In  the  majority  of  cases  the 
ulcer  is  on  the  anterior  wall  of  the  duodenum,  within  two  centi- 
meters of  the  pylorus.  The  pyloric  vein  is  regarded  by  surgeons 
as  a  line  of  demarcation  between  a  pyloric  and  a  duodenal  ulcer. 
The  ulcer  often  appears  as  a  simple  roundish  depression  in  the 
mucous  membrane,  having  the  muscular  coat  as  its  floor.  In 
other  cases  a  layer  of  thickened  peritoneum  forms  the  base;  or  it 
may  rest  on  the  pancreas,  liver,  or  gall  bladder. 

Etiology. — Curling  has  called  attention  to  the  fact  that  a  severe 
burn  or  scald  upon  the  surface  of  the  body  is  sometimes  followed 
by  ulcer  formation  in  the  duodenum.  This  has  often  been  clinically 
demonstrated.  Uremia  may  cause  duodenal  ulcer,  particularly 
in  the  presence  of  nephritis.  Etiologic  factors  may  be  found  in  a 
thrombosis  of  the  vessels  supplying  the  duodenum,  tuberculosis, 
traumatism,  toxins,  and  bacterial  infections. 

Some  clinicians  believe  that  hyperacid  chyme  in  the  duodenum 
may  originate  the  ulcer  by  its  effect  on  the  mucous  membrane.  xAs 
soon  as  this  chyme  has  been  neutralized  by  the  alkaline  juices  of 
the  duodenum,  it  ceases  to  irritate.  Owing  to  anatomic  forma- 
tion, the  alkaline  juices  reach  a  higher  level  in  females  than  in  males, 
and  it  is  a  fact  that  there  are  fewer  cases  of  duodenal  ulcer  in 
females  than  in  males. 

There  is  a  possibility  that  duodenal  ulcer  is  caused  by  the  absorp- 
tion of  toxic  substances  from  the  vermiform  appendix  or  the  colon. 
In  66  per  cent,  of  his  cases  of  duodenal  ulcer  requiring  operation 
Paterson  found  appendicular  disease  also.  In  none  of  these  cases 
was  there  any  clinical  reason  to  assume  the  existence  of  disease 
of  the  appendix.  It  has  been  estimated  that  36  per  cent,  of  all 
cases  of  ulcer  of  the  stomach  and  duodenum  are  associated  with  a 
diseased  appendix.  In  15  per  cent,  of  the  ulcer  cases,  cholecystitis 
and  cholelithiasis  are  present.  It  would  seem  that  the  exciting 
cause  is  bacterial,  proceeding  from  the  appendix  or  the  gall  bladder. 
45 


706  ULCERS  OF  THE  INTESTINE 

La  Roque  believes  the  original  source  of  the  bacteria  is  some  patho- 
logic area  of  the  abdomen  drained  by  the  portal  vein,  while  Rosenow 
says  the  focus  of  infection  is  a  diseased  condition  of  the  teeth, 
gums  and  tonsils,  with  its  accompanying  oral  sepsis  (see  page  290). 

It  has  been  demonstrated  experimentally  that  an  emulsion  of  a 
freshly  excised,  macerated  duodenal  ulcer  injected  into  the  ear  of  a 
rabbit  will  frequently  produce  an  ulcer  in  the  stomach  or  upper 
intestine.  Steinharter  produced  gastric  ulcer  in  rabbits  by  intra- 
venous inoculations  with  clumped  colon  bacilli,  and  more  recently 
with  staphylococci.  It  thus  seems  reasonable  to  assume  the 
possibility  of  a  secondary  infection  from  a  primary  focus  (see 
page  480). 

Duodenal  ulcer  is  of  more  frequent  occurrence  than  was  formerly 
assumed  by  pathologic  anatomists.  It  is  a  more  insidious  disease 
than  gastric  ulcer.  Though  more  often  associated  with  complica- 
tions, such  as  severe  hemorrhage  and  perforations,  the  symptoms 
before  the  onset  of  complications  are  much  lighter  than  those  of 
gastric  ulcer.     (See  Plate  XXVII.) 

Symptoms. — The  anamnesis  is  of  the  greatest  importance  in 
the  diagnosis  of  duodenal  ulcer.  The  patient  complains  of  a 
feeling  of  burning  and  fulness  in  the  gastric  region  two  to  four 
hours  after  meals  and  at  midnight,  and  describes  it  as  a  hunger 
pain.  These  symptoms  promptly  disappear  upon  ingestion  of 
food  or  alkalis.  The  symptoms  manifest  themselves  periodically 
and  may  have  existed  ten  to  twenty  years  or  even  longer.  In 
typical  cases  the  pain  is  located  in  the  hypochondriac  region  in  the 
right  parasternal  line,  about  two  centimeters  below  the  arch  of  the 
ribs.  Patients  may  have  symptoms  of  digestive  disorder,  of  which 
they  have  complained  as  long  as  they  can  remember.  The  ulcera- 
tion may  begin  early  in  life  and  continue,  the  severity  of  the  symp- 
toms depending  upon  the  degree  of  destruction  of  tissue.  In 
contradistinction  to  ulcer  of  the  stomach,  the  patients  complain 
of  distress  coming  on  two  or  more  hours  after  meals;  directly 
after  the  taking  of  food  there  is  no  pain.  At  times  the  pain  may 
be  delayed  until  three,  four  or  even  five  hours  after  meals.  The 
patients  call  it  a  hunger  pain,  for  the  reason  that  it  is  relieved  by 
eating. 

The  fulness  and  hunger  pain  may  be  present  for  a  few  weeks  or 
months  and  disappear  for  a  similar  period.  This  periodicity  is 
characteristic  of  the  disease.  These  symptoms  have  a  certain 
predilection  for  the  fall  and  winter  months.  Occasionally  par- 
oxysms of  pain  occur,  usually  in  the  upper  abdominal  region  or 
epigastrium,  with  radiation  toward  the  thorax  or  toward  the  back. 

There  is  usually  a  good  appetite,  and  no  vomiting  or  marked 
impairment  of  nutrition. 

These  symptoms  may  be  combined  with  others,  due  to  complica- 
tions  such   as   gastric  ulcer,   gastric   catarrh,    intestinal   catarrh, 


PLATE    XXVII 


Perforating  Duodenal  Ulcer  with  Hypertrophy  of  the  Pylorus 
and  Dilatation  of  the  Stomach. 


DUODENAL  ULCER  707 

appendicitis,  or  cholelithiasis.  Many  cases  of  duodenal  ulcer  are 
complicated   by   more  or  less  pronounced  neurasthenia   exerting 

an  influence  upon  the  symptom-complex,  'lucre  is  a  disturbance 
of  the  vegetative  nervous  system  (sec  page  :>S7).  There  are  often 
vasomotor  disturbances  which  manifest  themselves  in  cold  hands 
and  feet.  Some  cases  are  complicated  by  psychic  excitation  (see 
page  3S9). 

These  cases  often  remind  us  of  hyperacidity  and  hypersecretion. 
But  pains  at  night  in  cases  of  pure  hyperacidity  or  of  gastric  hyper- 
secretion are  certainly  rare;  nor  does  hunger  pain  occur  very  often 
in  uncomplicated  cases.  In  gastric  ulcer  the  pains  usually  occur 
one  or  two  hours  after  meals,  and  there  is  less  tolerance  for  coarse 
food  than  in  duodenal  ulcer  or  uncomplicated  hyperacidity.  Vomit- 
ing also  occurs  much  more  frequently  in  gastric  than  in  duodenal 
ulcer. 

Diagnosis. — For  diagnostic  purposes  it  is  necessary  to  distinguish 
between  two  principal  groups:,  cases  in  which  pain,  hyperacidity, 
severe  hemorrhage  or  perforation  has  occurred,  and  cases  in  which 
the  symptoms  are  not  prominent. 

A  peculiarity  of  the  hemorrhage  of  duodenal  ulcer  is  that  it  is 
intestinal.  "When  there  is  much  hemorrhage  the  feces  may  look 
like  tar  or  soft  asphalt.  Sometimes  they  are  formed  and  of  a/ 
brownish-black  color,  and  the  patient's  suspicion  of  hemorrhage 
is  aroused  only  by  noticing  a  margin  of  blood  around  the  feces  in 
the  water  after  an  evacuation.  When  the  hemorrhages  are  con- 
siderable they  may  lead  to  fainting  or  collapse.  In  most  cases  of 
duodenal  hemorrhage  the  patient  lacks  facial  color,  a  condition 
due  in  grave  cases  to  reduction  of  hemoglobin  and  erythrocytes. 
In  mild  cases,  however,  the  general  manifestations  are  slight, 
though  occult  blood  is  found  in  the  feces.  Oftentimes  patients 
attend  to  their  business,  and  are  quite  astonished  when  they  are 
told  about  their  hemorrhages.  Attention  is  directed  to  the  duo- 
denum by  dyspeptic  manifestations,  with  pressure,  a  feeling  of 
fulness,  and  pain,  two  hours  or  more  after  meals.  The  less  pro- 
nounced the  gastric  manifestations,  the  greater  the  probability 
of  the  hemorrhage  being  from  the  duodenum.  The  origin  of  the 
hemorrhage,  of  course,  locates  the  ulcer.  Hemorrhage  from 
cirrhosis  of  the  liver  must  be  excluded,  for  in  the  early  stage  of 
hepatic  cirrhosis  the  blood  may  pass  directly  through  the  mucous 
membrane  of  the  intestine.  Both  duodenal  ulcer  and  hepatic 
cirrhosis  are  most  apt  to  occur  in  middle  life,  in  the  male  by  prefer- 
ence. To  make  a  differential  diagnosis,  one  should  palpate  the 
liver  and  spleen,  and  remember  that  gastric  pains  occur  far  less 
often  in  hepatic  cirrhosis  than  in  gastric  and  duodenal  ulcer. 

It  may  be  easy  to  make  a  diagnosis  after  an  intestinal  hemor- 
rhage or  perforation,  or  it  may  be  quite  difficult.  Pain,  rigidity, 
nausea  and  vomiting  are  the  main  symptoms.     The  pain  is  sudden, 


708  ULCERS  OF  THE  INTESTINE 

agonizing,  unbearable.  It  is  usually  in  the  upper  part  of  the 
abdomen.  Patients  lie  supine,  with  anxious  faces,  flexed  thighs, 
and  tense  muscles.  Rigidity  of  the  abdominal  muscles  is  an  early 
symptom  and  is  always  present;  the  muscles  are  so  hard  that  they 
are  often  called  board-like.  Vomiting  is  usually  present,  although 
this  symptom  alone  cannot  be  depended  upon.  Perforation  may 
occur  without  the  slightest  shock;  then  again  the  shock  may  be 
most  pronounced.  Perforation  caused  by  a  duodenal  ulcer  may 
occasionally  be  mistaken  for  a  perforating  appendicitis;  but  this  is 
not  a  serious  error,  since  both  require  surgical  intervention.  (See 
Plate  XXVII.) 

Some  cases  of  perforated  duodenal  ulcer  may  give  no  previous 
history  of  ulcer  or  of  digestive  disorder.  The  perforations  occur 
while  the  patients  are  at  their  usual  occupations  or  during  the 
middle  of  the  night  while  they  are  in  bed  and  asleep. 

Severe  epigastric  pain  may  be  caused  by  an  acute  coccus  kidney, 
so-called — the  acute  hematogenous  kidney  first  described  by  Brewer. 
This  is  an  acute  infection  of  the  kidney  cortex  with  the  staphylo- 
coccus or  streptococcus,  and  the  symptoms  are  predominantly 
intestinal.  Before  we  knew  anything  of  the  existence  of  this  disease 
the  initial  operation  was  generally  done  for  gallstones  or  some 
acute  abdominal  condition. 

Chronic  cholecystitis  with  or  without  colics  may  also  have  to  be 
considered  in  the  differential  diagnosis,  as  well  as  chronic  appen- 
dicitis and  certain  forms  of  chronic  constipation.  Reflex  neuroses 
or  general  neurasthenia  may  occasionally  cause  certain  symptoms 
resembling  those  of  duodenal  ulcer.  All  these  things  must  be 
taken  into  account  in  determining  the  differential  diagnosis.  How- 
ever, the  combination  of  burning,  fulness,  and  pronounced  hunger 
pain  relieved  by  alkalis  or  food,  is  almost  conclusive  evidence  of 
duodenal  ulcer.  Periodical  colics,  especially  when  there  is  night 
pain,  may  enable  us  to  differentiate  from  cholelithiasis,  pancreatic 
lithiasis,  appendicular  colic,  right  renal  colic,  gastric  ulcer,  and 
such  cases  of  hyperacidity  and  hypersecretion  as  are  associated 
with  them.  Pyloric  fissure  or  erosion  readily  causes  temporary 
pylorospasm  in  the  presence  of  hypersecretion  (see  Pylorospasm, 
page  398). 

The  objective  findings  which  must  be  established  in  duodenal 
ulcer  are  of  particular  interest.  Palpation,  percussion,  the  deter- 
mination of  the  gastric  function,  and  the  demonstration  of  occult 
blood  in  the  feces,  all  have  a  bearing  on  the  differential  diagnosis. 
The  string  test  is  of  great  assistance  (see  pages  493-494). 

In  regard  to  palpation,  a  point  in  the  duodenum  showing  tender- 
ness on  pressure  should  be  sought,  but  caution  is  necessary  in 
discriminating  between  the  tenderness  of  duodenal  ulcer  and  that 
of  cholelithiasis.  It  can  easily  be  seen  by  Roentgen-ray  examina- 
tion, the  patient  standing,  that  the  horizontal  part  of  the  duodenum 


DUODENAL  ULCER  709 

is  usually  located  at  the  borderline  between  the  ninth  and  tenth 
dorsal  vertebrae;  it  lies  at  the  right  margin  of  these  vertebrae  and 
extends  beyond  them  by  two  or  three  ringers'  width;  rarely  is  it 
found  on  the  left  margin.  Mapped  upon  the  surface  of  the  body, 
it  corresponds  to  a  position  about  four  fingers'  width  above  the 
umbilicus,  between  the  right  sternal  and  the  parasternal  line. 

A  characteristic  pressure  point  does  not  exist  in  all  cases;  in 
some,  rigidity  (defence  musculaire)  in  the  upper  part  of  the  right 
abdominal  rectus  muscle  points  to  a  pathologic  condition  of  an 
organ  located  behind  it.  This  muscle  is  often  hypertrophied  and 
resistant  to  pressure. 

Stern  describes  a  posture  assumed  by  the  patient  which  is  an 
indication  of  ulcer  of  the  duodenum:  The  patient,  trying  to  stretch 
out  his  epigastrium  on  account  of  the  relief  obtained  thereby,  often 
prefers  standing  to  sitting;  when  in  discomfort  while  resting  on  a 
chair  he  sits  in  a  slanting  position  in  such  a  manner  that  chest, 
abdomen  and  legs  form  a  perfect  incline.  When  experiencing 
discomfort  while  in  bed,  the  patient  tries  to  lie  as  straight  as  possible, 
often  on  the  left  but  never  on  the  right  side. 

The  gastric  secretion  frequently  varies;  normal  secretion,  sub- 
acidity  and  hyperacidity  have  all  been  observed — hyperacidity 
oftener  than  subacidity.  Hypersecretion  and  continuous  secretion 
are  consistent  with  the  existence  of  a  duodenal  ulcer.  Roentgen- 
ray  examinations  have  shown  that  in  uncomplicated  cases  of  duo- 
denal ulcer  a  more  or  less  pronounced  degree  of  hypermotility  can 
exist.  This  finding  is  not  constant  nor  specific  for  duodenal  ulcer, 
for  hypermotility  is  usually  found  in  cases  of  achylia  gastrica. 
The  combination  of  hyperacidity  with  hypermotility  deserves 
special  consideration.  Any  lesion  in  the  duodenum  raises  the  tone 
and  motility  of  the  stomach. 

Examination  of  the  feces  is  especially  important  if  occult  blood 
is  repeatedly  found ;  but  reliable  methods  must  be  employed,  with 
exclusion  of  meat  from  the  diet.  The  benzidin  test  for  blood 
is  preferable  to  the  Weber  test.  The  positive  demonstration  of 
occult  hemorrhages  is  significant  in  proportion  to  the  number  of 
times  they  are  found,  and  the  importance  of  this  finding  increases 
with  the  objective  demonstration  of  anemia  without  other  probable 
cause  (see  page  123). 

The  test  for  occult  blood  in  the  gastric  contents  is  a  great  aid 
in  the  diagnosis  of  duodenal  ulcer  when  it  is  preceded  by  an  oil  test 
breakfast  (see  page  626).  The  oil  induces  a  regurgitation  of  duo- 
denal contents  into  the  stomach,  and  if  the  case  is  one  of  duodenal 
ulcer  blood  may  then  be  found  in  the  stomach  contents.  Gastric 
bleeding  should,  of  course,  be  excluded  by  an  examination  of  the 
stomach  contents  without  the  oil  test  breakfast. 

The  duodenal  tube  (Chapter  III)  should  be  used  to  confirm 
the  diagnosis.     Under  normal  conditions  the  bile  extracted  through 


710  ULCERS  OF  THE  INTESTINE 

the  tube  contains  no  blood  or  pus  cells.  In  duodenal  ulcer  we 
frequently  find  small  particles  of  coagulated  blood  or,  with  the 
aid  of  the  microscope,  blood  and  pus  cells  (see  page  110). 

Einhorn's  silk-string  test  should  never  be  overlooked  in  the 
diagnosis  of  duodenal  ulcer  (see  page  493).  In  duodenal  ulcer 
there  is  usually  a  stain  of  blood  on  the  string  between  60  and  70 
centimeters  from  the  knot  (Figs.  83  and  84).  If  this  test  be  made 
several  times  on  one  individual  and  each  time  a  red  or  brown  stain 
is  found  at  about  the  same  distance  from  the  knot,  a  lesion  of  the 
duodenal  mucosa  probably  exists. 

The  Roentgen  ray  is  of  great  assistance  in  the  diagnosis  (see  page 
143).  Hypermotility,  deformity  of  the  duodenal  cap,  and  pyloro- 
spasm  are  very  important  points  (Plate  XVI,  Figs.  2,  3  and  4). 

Polycythemia  is  frequently  found  in  duodenal  ulcer  and  rarely 
found  in  gastric  ulcer. 

There  is  no  single  symptom  pathognomonic  of  duodenal  ulcer. 
For  this  reason  it  is  necessary  to  make  a  critical  survey  of  all  the 
symptoms — to  strike  a  balance,  so  to  speak,  from  positive,  nega- 
tive and  doubtful  columns  of  evidence.  Often  the  diagnosis  cannot 
go  beyond  a  mere  presumption,  and  in  these  cases  it  is  necessary 
to  be  guided  by  a  number  of  general  considerations. 

The  first  is  the  fact  that  duodenal  ulcer  occurs  more  frequently 
in  men  than  in  women;  statistics  indicate  that  the  proportion  is 
about  four  to  one.  Seventy-one  per  cent,  of  Mayo's  cases  of  duo- 
denal ulcer  were  in  males.  This  may  be  partially  explained  by  the 
mode  of  life  led  by  men,  including  the  use  of  alcohol  and  nicotin 
and  exposure  to  traumatism. 

Duodenal  ulcer  is  comparatively  rare  before  puberty,  the  time 
of  its  most  frequent  occurrence  being  between  thirty  and  fifty 
years  of  age.  It  has  been  observed  in  the  new-born  and  is  occa- 
sionally found  in  young  marasmic  infants.  These  ulcers  are  easily 
overlooked — are  in  fact  found  only  by  those  who  are  especially 
looking  for  them.  They  may  be  acute  or  chronic,  and  their  patho- 
logic anatomy  closely  resembles  that  of  gastric  ulcer  in  the  adult. 
Duodenal  ulcer  has  been  reported  as  the  cause  of  melena  and 
pylorospasm  in  infants,  and  as  appearing  without  apparent  cause 
in  children  in  fairly  good  health.  These  ulcers  may  be  present 
even  when  there  is  no  macroscopic  evidence  of  blood  in  the  stools; 
and  the  practitioner  should  make  an  examination  with  the  benzi- 
din  test  (see  page  123)  for  occult  blood  in  the  feces  in  every  case  of 
wasting  infancy.  Such  a  procedure  may  furnish  valuable  informa- 
tion in  the  elucidation  of  infantile  atrophy  and  marasmus. 

Complications. — The  complications  of  duodenal  ulcer  are  hemor- 
rhage, perforation,  peritonitis,  cicatricial  stenosis,  contraction  of 
the  ampulla  of  Vater,  pancreatitis,  periduodenitis,  carcinoma, 
and  diseases  of  the  biliary  ducts  and  the  gall  bladder. 


DUODENAL  ULCER  711 

Prognosis.-  The  prognosis  of  duodenal  ulcer  is  more  favorable 
than  that  of  gastric  ulcer,  because  the  former  is  much  more  rarely 
succeeded  by  stenosis  or  carcinoma.  Recovery  may  be  expected 
as  a  result  of  appropriate  treatment.  It  must,  however,  be  borne 
in  mind  that  some  of  these  cases  are  so  obstinate  as  to  endanger 
life  through  their  complications.  The  complications  are  usually 
more  serious  in  their  nature  than  those  arising  from  ulcer  of  the 
stomach,  though  fortunately  they  are  less  frequent. 

In  many  cases  of  hyperacidity  or  hypersecretion,  manifestations 
suggestive  of  duodenal  ulcer  do  not  appear  until  small  superficial 
defects  of  the  duodenal  mucosa  have  taken  place,  inducing  a  super- 
ficial ulcer  which  becomes  latent  as  soon  as  it  heals.  We  should 
distinguish  between  a  light  (florid)  or  superficial  ulcer  and  a  chronic 
(callous)  indurated  one.  That  the  majority  of  duodenal  ulcers  are 
of  benign  character  is  supported  by  the  fact  that  neither  cicatriza- 
tion nor  malignant  changes  occur  here  as  frequently  as  in  gastric 
ulcer. 

This  method  of  reasoning  will  also  influence  the  treatment.  In 
cases  of  gastric  ulcer  there  is  not  only  the  ulcer  itself  to  be  con- 
sidered, but  also  the  hypersecretion  which  interferes  with  healing. 

Treatment. — The  internal  treatment  of  duodenal  ulcer  demands 
practically  the  same  attention  to  details  as  in  gastric  ulcer.  The 
Leube-Ziemssen,  the  Lenhartz  or  the  Sippy  treatment  is  indicated. 
In  stubborn  cases  Einhorn's  duodenal  alimentation  cure  is  successful 
(see  Chapter  XXV).  Above  all,  there  should  be  absolute  rest  in 
every  form — not  only  long  rest  in  bed,  but  in  the  early  stage  of  the 
treatment  absolute  rest  of  the  stomach  also.  This  is  indicated  not 
only  after  hemorrhages,  but  in  duodenal  ulcer  causing  pylorospasm, 
because  in  the  latter  case  it  is  clearly  important  that  the  contrac- 
tions of  the  pyloric  musculature  caused  by  ingestion  of  food  should 
be  arrested  for  a  time  or  restricted. 

When  feeding  by  mouth  is  begun,  it  is  well  to  reduce  the  hyper- 
acidity by  giving  butter,  cream,  yolk  of  eggs,  sugar  and  milk. 
If  the  gastric  secretion  is  good,  the  stomach  can  digest  coarser 
food  by  its  proteolytic  function,  changing  it  to  a  thin  mass.  The 
food  should,  however,  be  free  from  cellulose  and  coarse  raw  con- 
nective tissue.  The  ulcer  diet  should  be  maintained  for  a  prolonged 
period. 

The  medicinal  treatment,  which  is  identical  with  that  employed 
in  the  treatment  of  gastric  ulcer,  is  fully  described  on  pages  503- 
506. 

Dietetic  and  medicinal  treatment  is  to  be  tried  at  first  even  in 
rather  severe  cases  associated  with  repeated  hemorrhages  from  the 
bowel,  since  much  can  be  done  by  proper  dieting  and  the  admin- 
istration of  alkalis  to  overcome  hyperchlorhydria  and  thus  favor 
healing  of  the  ulcer.  In  acute  forms  of  duodenal  ulcer,  such  as 
those  due  to  toxic  causes,  to  uremia,  septicemia  or  surgical  pro- 


712  ULCERS  OF  THE  INTESTINE 

cedures,  as  well  as  in  ulcus  neonatorum,  the  best  procedure  consists 
in  stimulating  urinary  excretion,  combating  the  infection  or  other 
cause,  and  enhancing  the  resisting  powers.  In  subacute  forms  of 
duodenal  ulcer,  such  as  occur  when  the  hyperchlorhydria  is  in  its 
incipiency  or  appears  at  intervals  only,  medical  treatment  will 
usually  give  excellent  results.  In  distinctly  chronic  types  of 
ulcer  (callous),  however,  which  are  not  likely  to  respond  to  medical 
measures,  surgical  intervention  is  indicated.  Polyvalent  bacterial 
vaccines  assist  in  bringing  about  recovery  in  a  great  many  cases 
(see  page  506). 

Surgical  Treatment. — The  surgical  treatment  is  to  be  reserved  for 
positively  diagnosticated  cases  with  recurrent  hemorrhages  which 
have  defied  the  best  internal  treatment;  doubtful,  obstinate  cases 
that  have  defied  medical  treatment,  and  in  which  the  symptoms 
may  be  caused  by  cholecystitis  or  pericholecystitis;  and  cases  of 
perforation.  The  treatment  of  perforating  duodenal  ulcer  is  always 
surgical.  The  perforation  usually  occurs  in  the  anterior  wall  of 
the  proximal  portion  of  the  duodenum.  (See  Plate  XXVII  and 
page  507.) 

JEJUNAL  ULCER. 

Peptic  ulcers  of  the  jejunum  may  run  a  latent  course  to  perfora- 
tion, or  may  cause  severe  trouble  from  the  beginning.  Some  cases 
have  been  discovered  only  after  gastroenterostomy.  Prolonged 
internal  treatment,  as  for  duodenal  ulcer,  offers  better  prospects 
of  cure  than  surgery,  except  in  cases  of  perforation.  In  prophy- 
laxis, alkalis  and  careful  dieting  should  be  the  rule  after  gastro- 
enterostomy, as  in  the  case  of  benign  stomach  affections. 

A  return  of  symptoms  in  a  patient  on  whom  a  gastroenterostomy 
has  been  performed  is  often  indicative  of  a  gastrojejunal  ulcer  at  the 
site  of  operation.  Half  of  the  ulcer  is  on  the  gastric  and  the  other 
half  on  the  intestinal  side.  Gastrojejunal  ulcers  occur  in  about 
2  per  cent,  of  the  operated  cases.  Roentgenographically  these 
cases  show  marked  deformity  about  the  new  stoma.  Etiologically, 
in  the  majority  of  cases,  retained  unabsorbable  suture  material  is 
found.  Duodenal  alimentation  has  given  good  results  in  many 
of  these  cases  (see  page  500). 


CHAPTER  XLII. 
ULCERS  OF  THE  INTESTINE  (Continued). 

TYPHOID  ULCERS. 

A  number  of  acute  infectious  diseases  give  rise  to  the  formation 
of  ulcers  in  the  intestine.  Erysipelas,  variola,  anthrax  and  septi- 
cemia are  all  responsible  for  a  few  cases  of  intestinal  ulceration;  but 
the  ulcers  of  typhoid  fever  and  dysentery  are  well  known  and 
frequently  occupy  a  prominent  position  in  these  two  diseases. 
In  army  camps,  in  mining  camps,  and  in  great  public  works  bring- 
ing together  large  numbers  of  men  for  a  longer  or  shorter  time, 
there  is  seldom  the  proper  care  of  excreta,  and  in  many  instances 
typhoid  germs  are  carried  by  flies  from  the  latrines  and  privies  to 
food,  resulting  in  epidemics  of  typhoid  fever.  And  such  carriage 
of  typhoid  by  flies  is  by  no  means  confined  to  these  great  temporary 
camps.  In  farmhouses  in  small  communities,  and  even  in  the 
badly-cared-for  portions  of  large  cities,  typhoid  germs  are  carried 
from  excrement  to  food  by  flies;  so  that  the  proper  supervision 
and  treatment  of  the  breeding  places  of  the  house-fly  become  most 
important  elements  in  the  prevention  of  typhoid.  Howard  rightly 
believes  that  the  insect  we  now  call  the  "house-fly"  should  in  the 
future  be  termed  the  "typhoid  fly"  in  order  to  direct  public  atten- 
tion to  the  danger  of  allowing  it  to  flourish  unchecked. 

Dietetic  Treatment. — This  is  not  the  place  to  discuss  the  whole 
field  of  typhoid  fever  therapeutics.  The  reader  is  referred  to  the 
large  works  on  the  practice  of  medicine  for  a  full  discussion  of 
this  disease.  But  here  a  few  suggestions  may  be  made  with  refer- 
ence to  the  dietetic  treatment.  In  the  diet  of  patients  with  typhoid 
fever  it  has  been  the  leading  principle  up  to  the  present  time  to 
spare  the  diseased  bowel  to  the  greatest  extent  possible.  Typhoid 
fever  patients,  so  long  as  the  temperature  continued  above  normal, 
were  kept  on  a  purely  liquid  diet,  consisting  of  milk,  sugar,  pap, 
an  occasional  allowance  of  casein  preparations,  freshly  expressed 
meat  juice,  beef  tea,  meat  jelly,  thoroughly  softened  stale  white 
bread,  zwieback,  crackers  and  cocoa.  At  the  same  time  analeptics 
in  the  form  of  alcoholic  drinks  were  administered.  Only  after 
the  complete  disappearance  of  the  fever — no  rise  of  temperature 
for  five  to  eight  days — was  greater  variation  in  the  diet  and  a  little 
more  solid  food  permitted.     These  old  principles,  which  experience 


714  ULCERS  OF  THE  INTESTINE 

has  sanctioned,  are  now  being  assailed.  Warren  Coleman,  par- 
ticularly, pleads  for  a  fuller  diet,  having  found  that  hemorrhage 
of  the  bowel  and  relapses  were  no  more  frequent  after  more  solid 
nourishment  than  with  a  purely  liquid  diet.  He  has  observed  less 
weakness  and  fewer  complications  in  the  later  stages  of  typhoid  fever 
when  the  patients  had  been  fed  better.  Coleman  has  found  that, 
contrary  to  the  common  belief,  large  quantities  of  selected  foods 
can  be  taken  without  disturbance  of  digestion.  There  is  no  evi- 
dence to  indicate  that  the  duration  of  the  febrile  period  of  the 
disease  or  the  range  of  temperature  is  affected  by  diet,  except  that 
serious  recrudescences  are  rarer  in  patients  who  are  well  nourished. 
The  mortality  of  the  disease  is  reduced  50  to  75  per  cent,  by  high 
caloric  feeding.  Shaffer  and  other  clinicians  agree  with  this  view 
of  high  caloric  feeding,  and  it  has  now  come  about  that  the  per- 
missible diet  in  typhoid  is  quite  varied  except  in  cases  in  which 
such  feeding  is  impossible  on  account  of  somnolence  and  grave 
prostration.  Various  combinations  of  milk,  cream  and  lactose 
should  be  given  in  the  earlier  stages  of  the  disease.  Eggs  may  be 
added  to  make  up  the  protein  requirement.  Some  of  the  cream 
may  be  given  hi  the  form  of  ice  cream.  In  certain  cases,  if  patients 
have  difficulty  with  mastication,  custards,  mashed  potato,  cocoa, 
apple  sauce  and  cereals  are  given,  although  these  foods  are  usually 
more  suitable  later  in  the  course  of  the  disease.  Scraped  and 
chopped  meat  free  of  connective  tissue,  such  as  veal,  chicken, 
game,  brain  and  sweetbread,  vegetables  well  cooked  in  the  puree 
form,  such  as  mashed  potatoes,  rice  and  flour  porridge,  mashed 
spinach,  apple  sauce  and  tender  baked  foods  are  now  permitted  or 
even  recommended. 

A  high  caloric  diet  has  been  proved  to  be  of  greater  benefit  to 
typhoid  fever  patients  than  a  low  one.  Food  is  absorbed  by 
typhoid  patients  almost  as  completely  as  by  healthy  individuals. 
Under  proper  feeding  the  emaciation  formerly  seen  under  an 
exclusive  milk  diet  does  not  take  place.  Under  a  high  caloric  diet 
the  duration  of  the  disease  is  shortened.  Many  patients  feel  so 
well  that  they  are  able  to  resume  their  occupation  soon  after  their 
dismissal  from  hospital.  The  mental  condition  of  patients  who 
are  well  nourished  enables  them  to  keep  their  mouths  clean,  so  that 
the  poor  condition  of  the  tongue  and  lips  seen  in  milk-fed  patients 
does  not  exist.  Tympanites  and  diarrhea  are  less  frequent  and 
less  pronounced.  There  is  practically  complete  absence  of  ner- 
vous symptoms.  Intestinal  hemorrhage  does  not  occur  any 
oftener  than  with  low  caloric  feeding.  The  amount  of  food  given 
in  the  treatment  of  typhoid  fever  should  be  2500  calories  or  more 
in  the  twenty-four  hours.  A  number  and  variety  of  foods  may  be 
employed.  The  following  foods  have  been  given  thorough  trial 
and  are  recommended  for  appropriate  cases: 


TYPHOID  ULCERS  715 

I 1,  Amount.  Calories. 

Apule  sauce 1  ounce  30 

Bacon 1  ounce  240 

Bread Wcrago  slice  c;:;  ('.m.j  80 

Butter 1  pat  (J  ounce)  80 

Buttermilk 1  ounce  10 

Cereal  (.cooked) 1  heaping  tablespoonful  50 

( 'nickers 1  ounce  114 

Cream  (20  per  cent.)   ....  1  ounce  60 

Custard  (.baked) 1  ounce  180 

Egg 1  (2  ounces)  80 

Egg,  white 1  30 

Egg,  yolk 1  50 

Ice  cream 1  ounce  100 

Junket 1  ounce  35 

Lactose 1  tablespoonful  (9  Gm.)  36 

Lemonade 1  ounce  with  milk  sugar  120 

Milk  (.whole) 1  ounce  20 

Potato  (whole) 1  medium  90 

Potato  (mashed) 1  tablespoonful  70 

Rice  (boiled) 1  tablespoonful  60 

Sugar,  cane 1  lump  16 

Sugar,  milk 1  tablespoonful  36 

Toast Average  slice  80 

Whey 1  ounce  15 

Larger  quantities  of  each  article  should  be  given  at  each  suc- 
cessive feeding,  to  furnish  a  sufficient  number  of  calories.  If  the 
patient  is  given  a  clear  soup,  an  egg  nog  may  be  stirred  in.  Each 
egg  has  a  caloric  value  of  80,  and  if  six  eggs  are  given  during  twenty- 
four  hours  there  is  a  total  of  480  calories.  Feeding  at  two-hour 
intervals  has  been  found  most  satisfactory.  From  the  above  list 
of  foods  a  sufficient  variety  can  be  prescribed  to  tempt  the  appe- 
tite.    The  aim  should  be  to  give  approximately  3000  calories  daily. 

Houghton  reviews  various  physiologic  experiments  which  show 
that  during  the  fever  process  the  glandular  secretions  of  the  diges- 
tive tract  are  more  or  less  insufficient.  The  salivary  secretion  is 
less  than  normal,  and  may  even  become  acid.  This  is  one  of  the 
causes  of  the  dry  mouth,  coated  tongue,  and  sordes,  and  is  an 
indication  for  the  slight  salivary  stimulation  afforded  by  lemonade 
and  orange  juice.  The  hydrochloric  acid  of  the  stomach  is  greatly 
diminished,  and  it  is  still  further  decreased  in  amount  if  the  food 
does  not  contain  sodium  chlorid.  The  absence  of  sodium  chlorid 
from  the  diet  was  a  long-continued  mistake  during  the  milk-feeding 
period  of  typhoid  fever  treatment.  The  bile  and  the  pancreatic 
secretion  are  also  decreased.  It  has  been  estimated  that  the 
ability  to  digest  food  is  decreased  from  10  to  12  per  cent,  in  the 
typhoid  patient.  Hence,  as  the  absorbable  toxins  from  protein 
maldigestion  are  more  injurious  than  those  of  starch  maldigestion, 
the  deduction  seems  rational  that  too  much  protein  should  certainly 
not  be  administered. 

Chittenden  and  others  have  proved  that  in  protein  indigestion 
an  increased  amount  of  nitrogen  does  not  ordinarily  add  nutrition 
or  strength  to  the  system,  but  is  represented  by  an  increased  output 


716  ULCERS  OF  THE  INTESTINE 

of  nitrogen  products  in  the  urine,  the  body  taking  up  and  utilizing 
but  a  small  part  of  the  nitrogen  ingested.  This  is  certainly  just 
as  true  of  a  typhoid  patient;  and  the  nitrogen  that  passes  off  in 
the  urine  will  have  entered  into  irritating  and  even  more  or  less 
toxic  combinations  before  being  excreted.  It  would  therefore 
seem  advisable  to  give  the  typhoid  patient  just  sufficient  nitrogen 
for  his  needs,  as  approximately  estimated.  As  soon  as  convales- 
cence is  established  and  the  patient  begins  to  put  on  flesh,  he 
will  of  necessity  need  more  nitrogen — that  is,  more  protein. 

Another  effect  of  the  absorption  of  superfluous  nitrogen  com- 
pounds is  irritation  of  the  bloodvessels,  even  to  the  point  of  causing 
vasomotor  constriction.  This  constriction  of  the  surface  vessels 
during  fever  prevents  radiation  and  perspiration,  and  as  a  result 
the  skin  becomes  dry  and  hot  and  the  temperature  is  increased. 

If  the  patient  receives  an  unnecessary  amount  of  protein  and  an 
insufficient  amount  of  carbohydrate  during  the  fever,  the  increased 
quantity  of  ammonia  compounds  formed  may  develop  an  acidosis 
of  the  system  or  a  diminished  alkalinity  of  the  blood  which  may 
terminate  fatally. 

It  has  been  shown  that  during  fever  the  glycogen  in  the  liver  is 
diminished,  and  unless  starchy  foods  are  administered  it  may 
entirely  disappear,  all  the  glycogen  appearing  in  the  muscles. 
This  fact  probably  represents  a  need  of  the  cells  for  combustible 
material;  again,  another  indication  for  food  that  will  readily  form 
glycogen.  It  is  also  a  well-known  fact  that  the  part  of  the  body 
that  burns  first  in  protracted  fever  is  the  fat;  and  the  more  fat  the 
patient  has,  the  longer  probably  will  his  muscle  and  other  solid 
tissues  be  protected.  Also,  in  the  absence  of  carbohydrate  food 
his  body  fat  will  burn  to  such  acid  products  as  diacetic  and  beta- 
oxybutyric  acids  and  to  acetone,  with  the  result  of  causing  acidosis 
and  death.  Hence  it  is  wise  to  conserve  this  fatty  tissue  by  pro- 
tecting it,  and  to  prevent  acidosis  by  the  administration  of  such 
foods  (fats  and  starches)  as  will  furnish  material  for  the  fever 
process,  even  though  it  is  probably  impossible  for  the  patient,  under 
the  conditions,  to  deposit  new  fat.  In  other  words,  he  needs  more 
calories  than  he  has  been  receiving. 

While  it  is  well  known  that  glycogen  and  sugar  can  be  metabo- 
lized from  pure  protein,  as  evidenced  in  true  diabetes  meUitus,  it 
is  certainly  a  disadvantage  to  the  system  to  be  compelled  (and 
especially  during  a  fever)  to  make  its  glycogen  and  sugar  out  of 
protein  stuff.  Therefore  it  is  quite  evident  that  starch  should 
form  a  large  part  of  the  typhoid  fever  patient's  diet,  with  the 
addition  of  sugar. 

The  ideal  estimated  diet  of  a  typhoid  fever  patient  should  there- 
fore be:  a  small  amount  of  protein,  just  enough  to  represent  if 
possible  his  daily  nitrogen  loss;  as  much  carbohydrate  as  he  can 
comfortably  digest  without  the  production  of  flatulence,  given  in 


TV f ll(> II)  ULCERS 


the  fiirin  !>e>t  suited  to  the  individual  patient;  and  sodium  chlorid 
sufficient  for  liis  hydrochloric  acid  needs.  The  patient  should  also 
receive  some  fat;  and  he  should  have  plenty  of  water,  enough 

to  cause  him  to  pass  at  least  a  quart  of  urine  in  twenty-four  hour-, 
or,  better,  a  larger  amount. 

Houghton  has  drawn  up  a  diet  table  for  typhoid  fever,  with  the 
amounts  of  protein,  fat,  carbohydrate  and  calories. 


Percentage  of 

Hour. 

Material. 

wei^t.!    Apr0rtate 

Calo- 

Protein. 

Fat. 

Carbo- 
hydrate. 

ries. 

0  A.M. 

Choice  of: 
Toast       .      .      . 
Huntley  and  Pal- 
mer   breakfast, 
biscuit 

2  thin  slices. 
35  Gm.    5 

Zwieback 

3 

8.9 

1.4 

60.3 

125 

Cup  coffee,  sugar 

24  Gm.    2   heaping   teaspoon- 
fuls  sugar. 

100.0 

100 

Cream 

8  Gm.    1  dessertspoonful. 

2.4 

17.6 

4.5 

35 

8  A.M. 

Gruel,    cream    of 

wheat  . 

60  Gm.    2  heaping  tablespoon- 
fuls. 

9.3 

1.6 

74.0 

230 

10  A.M. 

Oyster  crackers 

30  Gm.    Large  handful. 

7.6 

8.2 

71.6 

130 

Vegetable  soup  . 

250  Gm.    8  ounces. 

6.3' 

Neg.2 

43.9 

190 

12   M. 

Baked  potato 
"       "  mashed 

SO  Gm.    Size  of  orange. 

1.9 

1.0 

20.0 

65 

and  creamed 

16  Gm.    1  tablespoonful. 

2.4 

17.6 

4.5 

35 

Butter      .      .      . 

8  Gm.    Size  of  domino. 

1.0 

80.8 

60 

Cup  hot  weak  tea, 

sugar    . 

24  Gm.    2   heaping   teaspoon- 
fuls  sugar. 

100.0 

100 

Toast       .      .      . 

35  Gm.    2  thin  slices. 

8.9 

1.4 

60.3 

125 

2  P.M. 

Tapioca  pudding 

60  Gm.    2  tablespoonfuls. 

2.8 

2.9 

28.2 

100 

Oyster  crackers 

30  Gm.    Large  handful. 

7.6 

8.2 

71.6 

130 

4  P.M. 

Rice    .... 

100  Gm. 

6.5 

0.3 

76.9 

350 

Butter      .      .      . 

8Gm. 

Size  of  domino. 

1.0 

80.8 

60 

Su^ar 

24  Gm. 

2  heaping     teaspoon- 

100. 0 

100 

fuls. 

6  P.M. 

Toast       .      .•     . 

35  Gm.    2  thin  slices. 

8.9 

1.4 

60.3 

125 

Butter 

8  Gm.    Size  of  domino. 

1.0 

80.8 

60 

Sugar 

12  Gm.    1    heaping   teaspoon- 
ful. 
250  Gm.    8  ounces. 

ldo'.o 

50 

8  P.M. 

Vegetable  soup  . 

6,3 

Neg.2 

43.9 

190 

Oyster  crackers 

30  Gm.    Large  handful. 

7.6 

8.2 

71.6 

130 

1  Percentage  of  solid  material. 

Negligible.  Weights  of  vegetables  are  those  prior  to  cooking.  Butter  washed  to 
remove  free  acid  is  preferred.  All  foods  to  be  thoroughly  cooked — four  hours  for 
vegetables  other  than  potato. 


The  Preparation  of  Vegetable  Soup. — Sixty  grams  each  of  green 
or  canned  French  peas,  white  dry  beans,  potato,  rice,  and  noodles, 
and  15  grams  of  carrots,  are  boiled  in  water  at  least  four  hours. 
Pmough  water  should  be  added  to  make  one  liter — which  is  suffi- 
cient for  four  feedings.  The  whole  yields  760  calories,  of  which  6.3 
per  cent,  is  protein,  less  than  0.2  per  cent,  fat,  and  -i.3.9  per  cent, 
carbohydrate.  When  ready  to  use,  stir  up  sediment  and  allow 
the  patient  to  eat  all  (including  noodles),  with  the  exception  of  the 
pea  and  bean  skins.     Onions  may  be  added  for  flavor  if  desired. 

General  Directions  for  Feeding. — The  patient  should  be  fed  with 
a  spoon  by  the  nurse. 

The  food  should  remain  in  the  mouth  as  long  as  convenient. 


718  ULCERS  OF  THE  INTESTINE 

Allow  water  between  feedings,  not  at  feedings. 

Allowances  or  corrections  are  to  be  made  for  increase  of  nitrogen 
need  during  the  first  ten  days  and  during  convalescence.  At  the 
height  of  fever,  if  the  patients  cannot  eat  the  full  quantity,  sub- 
stitute isodynamic  quantities  of  milk-sugar.  A  relative  decrease  of 
weight  should  be  reflected  in  the  caloric  value  of  the  food  on  the 
basis  of  4  kilograms  of  loss  per  week  of  disease. 

A  great  many  physicians  do  not  countenance  this  free  method 
of  feeding,  and  it  must  be  granted  that  in  many  cases  the  old 
method  appears  to  be  quite  satisfactory.  Experience  proves,  how- 
ever, that  the  more  liberal  feeding  in  cases  of  typhoid  fever  does 
not  cause  any  damage,  and  it  may  be  well  to  give  more  solid  food 
a  trial  in  selected  cases. 

Typhoid  Carriers.— Until  recently  surgical  drainage  of  the  gall 
bladder  was  the  only  successful  method  of  treatment  in  cases  of 
gall  bladder  infected  typhoid  carriers.  In  this  condition  we  can 
now  bring  about  a  complete  recovery  by  the  judicious  use  of  the 
duodenal  tube  (see  page  104). 


CHAPTER  XLIII. 
ULCERS  OF  THE  INTESTINE  (Continued). 

ACUTE  AND  CHRONIC  DYSENTERY. 

Dysentery  is  a  specific  febrile  disease,  with  inflammation  and 
ulceration  of  the  lower  ileum  and  colon.  It  is  caused  by  various 
infectious  agents,  of  which  the  microorganisms  mentioned  below 
have  been  differentiated: 

1.  Epidemic  dysentery.  This  disease  is  apt  to  make  its  appear- 
ance among  large  masses  of  people  living  under  faulty  hygienic 
conditions  and  on  poor  food,  as  in  prisons,  insane  asylums,  barracks, 
and  in  war.  It  is  caused  by  the  dysentery  bacillus  of  Shiga-Kruse- 
Flexner.  This  bacillus  resembles  the  typhoid  bacillus  somewhat, 
but  is  shorter  and  thicker,  non-motile  and  without  flagellse.  Epi- 
demic dysentery  occurs  very  frequently  in  Europe. 

2.  Endemic  dysentery  is  caused  by  the  Endameba  histolytica, 
Schaudinn,  and  prevails  in  tropical  countries  (Philippines,  Central 
America,  Southern  China,  Egypt,  Southern  Italy,  Balkan  States). 
Recent  work  on  the  endamebse  by  Craig  shows  that  Endameba 
tetragena  is  identical  with  Endameba  histolytica.  The  endamebse 
are  roundish  cells,  two  or  three  times  as  large  as  a  leukocyte,  and 
possess  great  motility;  they  form  pseudopodia,  by  the  aid  of  which 
they  are  enabled  to  insinuate  themselves  between  the  epithelial 
cells  of  the  intestine. 

3.  Reports  from  the  Philippines  show  that  dysentery  is  occasion- 
ally caused  by  the  Balantidium  coli.  This  organism  has  an  oval 
body  7  to  10  micromillimeters  in  length,  and  is  usually  found  in  the 
fresh  feces  in  pairs. '  It  produces  at  first  a  mild  intermittent  diar- 
rhea which  gradually  becomes  dysenteric  in  character.  Bilharzia 
hematobia  may  occasionally  produce  the  disease.  The  parasites 
Schistosma  japonica  and  Schistosma  hematobium  may  cause 
dysentery  when  they  enter  the  body  by  way  of  the  alimentary 
tract  in  the  drinking  water. 

4.  Dysentery  can  also  be  caused  by  Lamblia  intestinalis,  known 
also  as  giardia.  This  is  a  parasite  found  in  the  upper  part  of  the 
small  intestine  of  the  ordinary  house  mouse.  It  is  also  found  in 
the  rat,  cat,  dog,  rabbit,  sheep,  and  guinea-pig.  Man  is  infected 
by  eating  food  soiled  with  the  excreta.  The  parasite  attaches 
itself  to  the  small  intestine  by  means  of  its  sucker.  It  is  a  flagellate 
protozoan  and  may  be  found  rapidly  moving  in  the  warm  stools. 


720  ULCERS  OF  THE  INTESTINE 

In  the  endemic  form  of  dysentery  the  infection  takes  place  chiefly 
through  the  medium  of  the  feces,  due  to  improper  sewerage.  It 
can  also  be  conveyed  by  direct  transmission  from  man  to  man  and 
by  infected  water. 

Pathology. — The  same  pathologic  picture  is  presented  by  the 
fully  developed  ulcerative  stage  in  all  forms  of  acute  and  chronic 
dysentery.  In  the  large  intestine  irregular  large  and  small  ulcers, 
with  overlapping  edges,  become  confluent  and  threaten  to  destroy 
large  areas  of  the  mucous  membrane.  The  non-ulcerated  mucous 
membrane  is  dark  red,  swollen,  covered  with  polypoid  granulations, 
and  in  a  condition  of  severe  catarrh.  To  this  are  added  abscesses, 
deeply  situated  in  the  intestinal  wall,  which  may  perforate  into 
the  lumen  of  the  intestine  or  externally  into  cavities  formed  by 
inflammatory  adhesions,  or  more  rarely  into  the  free  peritoneal 
cavity.  Thus  abscesses  may  develop  outside  of  but  in  the  neigh- 
borhood of  the  large  intestine.  The  parts  most  frequently  diseased 
are  the  descending  colon,  the  sigmoid  flexure,  and  the  rectum; 
but  it  is  possible  for  the  whole  colon  to  be  affected.  The  develop- 
ment of  the  ulcers  varies  in  the  different  forms  of  dysentery.  Epi- 
demic dysentery  commences  with  a  catarrh  of  the  colon,  to  which 
is  soon  added  a  disseminated  diphtheritic  necrotizing  inflammation 
of  the  mucous  membrane  due  to  the  influence  of  the  bacilli  of 
dysentery,  accompanied  by  extravasation  of  blood  and  swelling  of 
the  follicles.  When  the  necrotic  epithelium  has  been  desquamated, 
ulcers  are  developed  at  the  spots  denuded  of  epithelium,  until 
finally  the  above-described  appearance  of  a  fully  developed  dysen- 
tery is  brought  about.  In  endemic  dysentery  the  disease  com- 
mences in  the  submucosa.  The  endameba?  which  have  made  their 
way  through  the  epithelium  into  the  submucosa  cause  infiltration, 
inflammation  and  granulation,  which  undergo  purulent  degenera- 
tion and  form  an  ulcer.  Only  from  that  spot  the  mucous  membrane 
disintegrates  and  the  ulceration  develops.  In  the  interval  between 
the  beginning  of  the  disease  and  the  end  of  the  grave  chronic  final 
stage,  come  all  the  steps  of  the  various  forms  of  inflammation  of  the 
mucous  membrane  and  of  the  formation  of  small  or  large  ulcers 
which  are  characterized  clinically  as  either  grave  or  light  cases. 

Symptoms. — Acute  and  chronic  dysentery  are  differentiated 
clinically.  The  acute  form  usually  appears  suddenly,  without  any 
previous  symptoms.  After  a  short  period  of  catarrhal  phenomena 
(slight  diarrhea),  there  occur  frequent  evacuations  of  the  bowel, 
and  the  feces  are  mixed  with  mucus,  blood,  and  pus.  During 
the  first  few  days  these  stools  contain  some  fecal  matter,  but  later 
they  consist  of  mucus,  blood  and  pus  only.  When  they  contain 
much  blood  they  are  darkened  and  the  case  is  called  red  dysentery; 
when  pus  predominates  the  disease  is  denominated  white  dysentery. 
The  number  of  the  stools  may  reach  twenty  or  even  thirty  within 
twenty-four  hours.     In  the  course  of  these  diarrheas  the  patient 


ACUTE  AND  CHRONIC  DYSENTERY  721 

is  annoyed  by  tenesmus  and  colicky  abdominal  pain-.  Soon 
genera]  symptoms  make  their  appearance,  as  lexer,  lassitude, 
emaciation,   vomiting,   anorexia    and   greal    thirst.    The   disease 

persists  in  this  manner  for  seven  to  ten  days,  and  when  successfully 
treated  improvement  follows  in  about  two  or  three  weeks,  and 
finally  recovery.  The  routine  microscopic  examination  of  the 
stools  for  endamebse  in  all  eases  of  bowel  disease  in  warm  climates 
will  alone  clear  np  the  diagnosis.  In  the  majority  of  cases  the 
pathogenic  organism  is  easily  and  quickly  found,  on  examining  a 
drop  of  the  blood-stained  mucus,  thinly  spread  out  under  a  cover- 
glass  on  a  warm  slide,  with  an  ordinary  |-ineh  lens.  Intestinal 
disturbances  simulating  amebic  dysentery  may  be  due  to  an  ameba 
known  as  ( Iraigia  migrans.  Emetin  is  very  effective  in  the  treat- 
ment of  this  as  well  as  the  commoner  forms  of  amebic  dysentery. 

Complications. — The  disease  may  be  complicated  by  perforations, 
abscesses,  and  exudates  into  the  perienteric  connective  tissue.  A 
frequent  complication  in  amebic  dysentery  is  abscess  of  the  liver, 
caused  by  migration  of  endameba?  into  that  organ. 

It  follows  from  the  foregoing  that  the  disease  is  always  a  grave 
one  and  that  it  is  impossible  to  form  a  clear  opinion  at  the  outset 
as  to  its  course.  Recovery,  however,  is  altogether  possible  under 
proper  treatment  in  both  the  acute  and  chronic  stages. 

Prophylaxis. — During  epidemics  of  dysentery  it  is  essential  that 
the  stools  be  disinfected  and  that  the  refuse  water  be  well  drained 
away.  The  supply  of  drinking  water  must  be  pure — boiled  if 
necessary.  The  friends  and  nurses  must  be  instructed  to  keep 
themselves  scrupulously  clean  and  to  disinfect  their  hands  and 
clothing  thoroughly. 

Prognosis. — With  regard  to  prognosis,  recoveries  are  more  apt  to 
occur  in  acute  than  in  epidemic  dysentery,  and  much  more  likely 
than  in  sporadic  endemic  dysentery.  The  acute  cases  sometimes 
pursue  a  comparatively  mild  course  and  end  in  early  recovery. 

When  recovery  is  not  absolute,  amebic  dysentery  may  continue 
and  the  symptoms  of  the  disease  never  entirely  disappear.  In  some 
eases  the  symptoms  at  first  entirely  disappear  for  a  considerable 
time,  even  for  months,  but  acute  relapses  repeatedly  follow  the 
slightest  errors  in  diet,  colds,  or  some  unknown  cause.  These 
relapses  may  become  more  and  more  serious  in  character,  so  that 
the  patient  is  gradually  brought  to  a  very  low  ebb,  as  regards  both 
his  physical  and  his  mental  condition;  anemia  sets  in,  and  in  time 
there  supervenes  a  condition  of  severe  inanition;  it  may,  however, 
be  years  before  this  stage  is  reached.  In  other  cases  the  intestinal 
disturbances  never  yield  after  the  acute  stage  has  been  overcome, 
diarrhea  keeping  up  persistently  and  sometimes  revealing  blood 
or  pus.  When  a  case  is  seen  in  this  stage,  the  diarrhea  having 
persisted  for  years,  it  often  happens  that  the  diagnosis  of  dysentery 
is  not  immediately  made.  Unless  the  symptoms  improve,  such 
46 


722  ULCERS  OF  THE  INTESTINE 

chronic  invalids  decline  more  rapidly  than  the  subacute  cases  and 
finally  succumb. 

Treatment  of  Acute  Dysentery. — The  method  of  treatment  at 
the  onset  of  the  disease  is  similar  to  that  adopted  in  cases  of  severe 
febrile  intestinal  catarrh.  During  the  first  days,  strict  rest  in  bed 
and  complete  fasting  or  pseud onutrition  must  be  enforced,  together 
with  the  administration  of  a  purgative  (castor  oil,  calomel,  sodium 
sulphate)  in  order  to  free  the  bowel  as  much  as  possible  from  disease 
germs  and  disintegrating  or  decomposed  materials.  Warmth  should 
be  freely  applied  to  the  abdomen.  The  diet  should  be  purely 
liquid,  mucilaginous  and  antiputrefactive  during  the  further  course 
of  the  disease  (see  page  174).  Milk  is  to  be  avoided.  The  follow- 
ing must  also  be  absolutely  prohibited:  meat  broth,  meat  extracts, 
albumoses  and  peptones.  For  thirst,  rice  and  sago  waters,  port 
wine  and  astringent  claret  can  be  given.  Lemonades  and  mineral 
waters  are  to  be  prohibited.  Very  gradually,  and  only  when  the 
stools  begin  to  show  a  feculent  character,  a  return  to  normal  diet  is 
attempted.  Great  caution  must  be  exercised  in  this  respect,  and 
not  until  the  stools  have  shown  themselves  quite  normal  for  weeks 
may  a  full  ordinary  diet  be  tentatively  permitted.  Even  then  it 
is  necessary  to  avoid  for  a  long  time  any  kind  of  solid  food  and 
articles  of  diet  which  are  highly  seasoned  or  rich  in  residue.  A 
constipating  diet  (see  page  172)  must  be  continued  for  several 
weeks. 

Medicinal  Treatment. — In  addition  to -adherence  to  the  strictest 
dietetic  regulations,  medication  plays  a  very  important  part  in 
the  treatment  of  acute  dysentery.  The  radix  ipecacuanhas,  the 
root  of  the  Brazilian  ipecacuanha,  termed  "dysentery  root"  in 
the  tropics,  is  the  particular  drug  that  exerts  a  directly  specific 
action  in  amebic  dysentery.  It  is  now  quite  clear  to  what  par- 
ticular constituent  of  the  root  the  satisfactory  effect  obtained 
should  be  ascribed.  The  root  contains  a  peculiar  tannic  acid  and 
several  alkaloids,  the  most  important  of  these  being  emetin  and 
cephaelin,  to  which  its  virtue  is  due.  It  is  an  established  fact  that 
the  symptoms  may  be  distinctly  improved,  and  at  times  even  an 
acute  amebic  attack  prevented,  by  the  use  of  ipecacuanha.  The 
drug  is  not  similarly  efficacious  in  bacillary  dysentery.  When 
the  diagnosis  is  certain,  ipecac  is  given  in  powders  of  1  Gm.  (15 
grains)  two  to  four  times  for  one  day.  Before  each  dose,  twenty 
drops  of  tincture  of  opium  should  be  given,  or  0.01  Gm.  (|  grain) 
morphin  subcutaneously,  for  the  purpose  of  preventing  vomiting. 
During  this  day  the  patient  must  abstain  entirely  from  food  of 
every  kind,  the  only  thing  allowed  being  a  very  small  amount  of 
cracked  ice  at  long  intervals.  The  medication  may  possibly  have 
to  be  repeated.  Ipecac  may  also  be  administered  in  the  form  of 
a  decoction,  in  tablespoonful  doses,  at  short  intervals  for  several 
days.  Large  doses  of  ipecac  destroy  not  only  the  living  Endameba 
histolytica,  but  also  the  encysted  forms  of  this  organism. 


ACUTE  AND  CHRONIC  DYSENTERY  723 

The  administration  of  ipecac  through  the  duodenal  tube  (Fig. 
11)  lias  been  distinctly  efficacious.     Beck  used   \  to  8  Gm.  <1  t<> 

2' drams)  of  powdered  ipecac  in  warm  water  or  suspended  in  acacia 
mucilage.  Two  to  six  doses  were  given,  at  intervals  of  one  to 
three  days.  There  was  occasional  nausea  and  vomiting.  The 
drug  does  not  irritate  the  stomach  when  given  in  this  way.  Sim- 
ilarly, wine  of  ipecac  in  doses  of  30  to  150  Cc.  (one  to  five  ounces) 
can  be  administered  by  instillation  daily.     (See  Chapter  III.) 

Much  contradictory  evidence  has  been  given  on  the  effectiveness 
of  ipecacuanha  in  the  treatment  of  dysentery.  It  is  largely  through 
the  efforts  of  Major  Leonard  Rogers,  Professor  of  Pathology  in  the 
Medical  College  of  Calcutta,  that  ipecacuanha  has  been  restored 
to  favor.  In  his  well-known  work  on  Fevers  in  the  Tropics  he 
points  out  that  the  ipecacuanha  treatment  of  amebic  hepatitis 
prevents  the  occurrence  of  suppurative  hepatitis,  or  tropical  liver 
abscess — that  this  complication  could  be  entirely  avoided  if  the 
treatment  by  ipecacuanha  were  employed.  Suppurative  hepatitis, 
in  his  opinion,  may  well  be  included  in  the  list  of  maladies  which 
recent  research  work  has  largely  conquered;  fatal  cases  in  the  British 
Army  in  India  have,  it  appears,  been  greatly  reduced  within  the  past 
few  years. 

Credit  must  again  be  given  to  Rogers  for  the  first  experimental 
results  in  the  treatment  of  dysentery  with  emetin,  the  active 
principle  of  ipecacuanha.  He  found  that  on  placing  a  piece  of 
mucus  containing  numerous  active  endamebse  in  normal  saline 
solution  with  emetin  hydrochlorid,  the  pathogenic  organisms 
were  immediately  killed  and  materially  altered  in  microscopic 
appearance  by  a  1 :  10,000  solution,  while  after  a  few  minutes  they 
were  rendered  inactive  and  apparently  killed  by  as  weak  a  solution 
as  1  :  100,000.  He  found  also  that  this  powerful  alkaloid  could 
be  safely  administered  hypodermically  in  the  treatment  of  amebic 
dysentery. 

The  subcutaneous  injection  of  soluble  salts  of  emetin  is  now 
known  to  be  a  specific  remedy  for  amebic  hepatitis  and  amebic 
dysentery.  The  hydrochlorid  of  emetin  is  used  on  account  of  its  free 
solubility.  The  dose  is  0.03  to  0.04  Gm.  (§  to  f  grain)  twice  daily 
for  three  consecutive  days  and  then  on  alternate  days  until  the 
clinical  symptoms  have  cleared  up.  It  is  rarely  necessary  to  give 
more  than  0.5  Gm.  (8  grains).  The  extraordinary  rapidity  with 
which  very  marked  improvement  follows  the  subcutaneous  injec- 
tion of  0.03-Gm.  (^-grain)  doses  of  emetin  hydrochlorid  is  of  the 
greatest  diagnostic  importance.  In  cases  of  bacillary  dysentery 
and  other  non-amebic  affections  the  drug  has  no  material  effect 
on  the  progress  of  the  disease.  The  effect  of  this  new  treatment 
furnishes  a  very  reliable  clinical  differentiation  between  the  two 
types  of  dysentery,  which  is  of  great  advantage  to  the  clinician. 

Emetin  hydrochlorid  can  be  administered  intravenously.     The 


724  ULCERS  OF  THE  INTESTINE 

pulse  may  occasionally  be  tense  or  intermittent,  but  in  the  main 
the  treatment  is  safe  as  well  as  satisfactory.  The  dose  is  0.06 
Gm.  (1  grain)  in  1  Cc.  (16  minims)  of  water. 

The  toxic  effect  of  emetin  on  the  endameba  is  due  to  the  benzyl 
esters  it  contains.  Benzyl  benzoate  acts  as  a  synergist  with  ipe- 
cacuanha or  its  alkaloids  and  shortens  the  attack.  It  takes  the 
place  of  morphin  in  that  it  slows  the  peristalsis  and  relieves  the 
pain  and  tenesmus.  The  20-per-cent.  alcoholic  solution  of  benzyl 
benzoate  should  be  given  in  doses  of  2  Cc.  (30  minims)  in  a  half- 
tumbler  of  water  three  times  daily  (see  page  276).   • 

Hemorrhagic  gastroenteritis  has  been  produced  experimentally 
with  emetin  by  a  number  of  investigators.  It  may  be  difficult 
to  recognize  emetin  diarrhea  in  the  course  of  treatment,  because 
the  symptoms  and  the  gross  appearance  of  the  stools  are  almost 
indistinguishable  from  those  of  amebic  dysentery.  Increase  in 
the  doses  of  emetin  must  be  made  with  caution. 

A  saline  cathartic  or  an  effective  dose  of  castor  oil  is  advisable 
as  a  preliminary  to  the  emetin  treatment;  and  this  should  be 
followed  up  by  an  occasional  saline  throughout  the  treatment. 
Thus  not  only  are  the  dead  endameba?  washed  out  of  the  bowel, 
but  the  encapsulated  ones  are  drawn  out  of  their  protected  positions 
and  attacked  by  the  emetin.  It  is  these  encysted  amebse  that 
account  for  the  recurrence  of  the  disease  after  treatment.  To  per- 
manently eradicate  the  infection  it  is  advisable  to  give  a  second 
course  of  emetin  injections  about  two  weeks  after  the  first,  and 
a  third  course  about  three  weeks  later. 

Good  results  are  reported  from  the  internal  administration  of 
emetin-bismuth  iodid  in  the  treatment  of  amebic  dysentery.1  The 
dose  is  0.2  Gm.  (3  grains)  in  capsule  every  night  for  twelve  con- 
secutive nights.  The  drug  is  apt  to  produce  nausea  and  vomiting 
unless  these  complications  are  guarded  against.  Should  there  be 
any  sign  of  nausea,  boiling  water  should  be  sipped.  During  the 
course  the  patient  is  best  kept  quiet  in  bed.  For  the  first  few 
nights,  or  until  tolerance  for  the  drug  is  well  established,  the  pillows 
should  be  removed.  In  the  event  of  salivation,  the  saliva  should 
not  be  swallowed,  but  expectorated  or  removed  with  cotton  swabs. 
It  is  said  that  the  curative  effects  of  the  emetin-bismuth  iodid 
treatment  are  usually  permanent. 

The  combined  treatment,  emetin  hypodermically  and  emetin- 
bismuth  iodid  by  mouth,  gives  the  best  results.  Emetin  is  given 
in  doses  of  0.06  Gm.  (1  grain)  for  five  days,  and  the  emetin-bismuth 
iodid  in  salol-coated  pills  in  doses  of  0.2  Gm.  (3  grains)  daily  for 
twelve  days.  Treatment  is  begun  with  both  medicaments  on  the 
same  day. 

1  The  Lancet,  March  31,  1917,  p.  482. 


ACUTE  AND  CHRONIC  DYSENTERY  725 

Epinephrin  will  promptly  relieve  the  dysenteric  pains.  Admin- 
istered  internally  it  relieves  not  only  the  pain  but  also  the  nausea, 
as  well  as  the  hiccough  which  is  often  a  troublesome  complication. 
Ordinarily  the  patient  is  given  10  to  20  drops  of  a  1:1000  solution 
in  water  every  hour  or  two. 

Arsphenamine  can  be  introduced  into  the  circulating  blood  in 
sufficient  strength  to  kill  the  endamebae  without  endangering  the 
host.  Intravenous  injections  of  0.6  Gm.  (10  grains)  of  arsphenamine 
appear  to  yield  excellent  results.  Winn  reports  11  cases  in  which  the 
endamebae  disappeared  from  the  stools  in  twenty-four  to  seventy- two 
hours  after  arsphenamine  was  administered. 

Li  oriental  countries  simaruba  bark  is  frequently  employed,  and 
to  it  are  ascribed  virtues  similar  to  those  of  ipecac.  Its  active 
principle  is  a  bitter  glucoside,  quassin.  The  bark  is  given  in  the 
form  of  a  decoction  (1:10,  one  tablespoonful  every  two  hours),  or 
as  wine  of  simaruba.  Uzara  also  has  a  striking  and  prompt  effect 
in  amebic  dysentery  (see  page  276). 

During  the  Boer  war  cases  of  acute  dysentery  in  South  Africa 
were  said  to  improve  under  treatment  with  magnesium  sulphate  in 
hourly  doses  and  proper  diet.  On  admission  to  the  hospital  the 
patient  was  given: 


Gm.  or  Cc. 

30 

0 

Si 

1 

5 

rrixxiv 

30 

0 

Si 

1$ — Olei  ricini 

Tincturae  opii 

Aquae  menthae  piperitae 
Misce. 
Sig. — At  once. 

And  as  soon  as  the  bowels  had  been  thoroughly  cleared: 

Gm.  or  Cc. 

]$ — Magnesii  sulphatis 4  0  3j 

Acidi  sulphurici  diluti 10  TTlxv 

Aquae  menthae  piperitae      ....       4  0  5j 

Misce. 

Sig. — To  be  given  every  hour  until  the  stools  become  feculent. 

As  the  tenesmus  wTas  relieved  and  the  evacuation  of  blood  and 
mucus  ceased,  the  sulphate  of  magnesium  was  administered  corre- 
spondingly less  frequently,  but  was  always  continued  for  about 
forty-eight  hours  after  the  dysenteric  symptoms  had  ceased.  The 
diet  consisted  of  arrowroot,  milk,  soda  water,  and  brandy  or  port 
wine. 

The  bark  of  catechu  is  also  a  favorite  drug.  It  is  administered 
either  as  a  powder,  0.1  to  0.3  Gm.  (2  to  5  grains)  three  times  a 
day;  in  the  form  of  keratinized  pills  of  catechu,  0.2  Gm.  (3  grains) 
eight  to  ten  times  a  day;  or  in  the  compound  tincture  of  catechu, 
in  teaspoonful  doses  six  to  eight  times  a  day.  The  usual  intestinal 
astringents  (see  page  276)  are  also  employed. 


726  ULCERS  OF  THE  INTESTINE 

Iodoform  is  also  given  internally,  either  0.05  Gm.  (1  grain)  iodo- 
form with  0.03  Gm.  (f  grain)  opium,  or  combined  with  bismuth: 

Gm.  or  Cc. 

I? — -Bismuthi  salicylatis 2(0  3ss 

Iodoformi 0|3  gr.  v 

Misce  et  ft.  pulv.  no.  vi. 
Sig. — One  powder  daily. 

Iii  the  Panama  Canal  Zone  amebic  dysentery  is  treated  with 
large  doses  of  bismuth  subnitrate.  The  method  consists  of  com- 
plete rest  in  bed,  milk  diet,  colonic  irrigation  with  normal  saline, 
and  bismuth  by  mouth.  In  severe  cases  a  heaping  teaspoonful  of 
bismuth  subnitrate,  suspended  in  a  tumblerful  of  plain  or  effer- 
vescent water,  is  given  every  three  hours  day  and  night,  the  amount 
being  decreased  only  when  improvement  is  maintained.  The  only 
alarming  symptom  that  may  occur  is  cyanosis,  and  this  quickly 
subsides  on  the  administration  of  magnesium  sulphate.  It  is 
assumed  that  the  drug  does  not  act  upon  the  microorganism  of  the 
disease,  but  upon  the  associated  putrefactive  symbiotic  bacteria, 
the  presence  of  which  is  essential  for  its  growth.  In  fifteen  to 
twenty  days  after  the  beginning  of  the  treatment  the  bismuth 
subnitrate  passes  through  the  bowel  white  and  unchanged.  By 
this  time  the  putrefactive  bacteria,  which  usually  liberate  the 
nascent  sulphur  in  the  proteins,  are  destroyed,  and  the  bismuth 
is  not  converted  into  the  sulphid. 

Salol  can  also  be  employed: 

Gm.  or  Cc. 

B — Salolis, 

Bismuthi  subnitratis, 

Sodii  bicarbonatis aa    0  ]  3  gr.  v 

Extracti  opii 0,015  gr.  \ 

Misce  et  ft.  pulv.  no.  i. 

Sig. — One  powder  three  or  four  times  daily. 

Kaolin,  bolus  alba,  or  talcum  may  also  be  used  (see  page  279). 

The  local  treatment  per  rectum  of  the  diseased  intestine  is  very 
important  and  is  applied  in  the  form  of  medicated  irrigations. 
Alleviation  of  the  pains  and  tenesmus  and  diminution  of  the  blood 
in  the  stools  follow  irrigations  with  hot  solutions  of  epinephrin; 
add  10  to  20  drops  of  the  commercial  1 :  1000  solution  of  epinephrin 
to  1  liter  (1  quart)  of  water  at  110°  to  120°  F.,  and  inject.  Or 
peroxid  of  hydrogen,  methylene  blue,  or  permanganate  of  potassium 
may  be  added  to  the  hot  water.  Enemata  of  1  to  5  per  cent. 
silvol  are  often  of  benefit.  American  investigators  have  advised 
cold  enemata,  and  the  application  of  ice-bags  to  the  region  of  the 
large  intestine,  because  of  the  sensitiveness  of  the  endamebse  toward 
cold.  Some  authors  employ  in  dysentery  the  treatment  recom- 
mended by  Cattani  in  cholera,  which  consists  of  tannic  acid  entero- 
clysis:  2  to  2^  liters  (quarts)  of  a  lukewarm  0.5-per-cent.  tannin 
solution  is  introduced  slowly  into  the  large  intestine  two  or  three 
times  daily,  and  kept  there  for  at  least  ten  minutes  (see  page  232). 


ACUTE  AND  CHRONIC  DYSENTERY 

The  pains  and  tenesmus  may  be  relieved  by  suppositories  <>f 

opium,   cocain,  epinephrin,  or  extract  of  bellad ia;  or  by  the 

administration  by  mouth  of  10  to  20.  drops  of  epinephrin  1:1000,  a 
procedure  which  has  been  found  to  be  safe  and  harmless.  Good 
effects  may  be  obtained  by  hydrotherapeutic  procedures  such  as 
moist  heat  and  warm  packs  to  the  abdomen. 

During  the  past  few  years  the  serum  treatment  of  epidemic 
dysentery  has  been  made  the  subject  of  various  experiments. 
Vaillard  and  Depter  have  prepared  an  antidysenteric  serum  which 
is  said  to  have  a  very  beneficial  effect,  the  number  of  stools  dimin- 
ishing immediately,  with  subsequent  improvement  of  the  general 
condition.  They  recommend  their  serum  as  the  only  effective 
therapeutic  agent  in  the  treatment  of  bacillary  dysentery.  In 
cases  of  doubtful  origin,  combined  treatment  with  emetin  and 
polyvalent  antidysenteric  seruni  is  recommended.  Shiga  also 
has  prepared  an  immunizing  serum  with  wThich  he  has  obtained 
good  results  in  cases  of  dysentery  caused  by  the  Shiga-Kruse 
bacillus;  this  serum  antidotes  the  Flexner  bacillus  also,  but  to  a 
decidedly  less  extent.  A  polyvalent  immunizing  serum  has  been 
prepared  by  Coyne  and  Auche;  it  is  obtained  from  a  single  horse 
immunized  against  three  distinct  bacterial  cultures.  An  injec- 
tion of  60  to  80  Cc.  of  a  multivalent  antidysenteric  serum  acts 
remarkably  well  in  a  majority  of  cases.  Striking  results  are  reported 
in  chronic  relapsing  cases  of  dysentery  from  the  use  of  a  small 
dose  of  stock  vaccine  at  fixed  intervals.  The  vaccine  employed  is 
prepared  from  a  culture  of  the  Shiga-Kruse-Flexner  bacillus,  heated 
to  60°  C.  and  suspended  in  salt  solution.  Stock  vaccines  sensi- 
tized with  antidysenteric  serum  have  given  striking  results;  the 
single  dose  never  exceeds  100,000,000  bacteria. 

Treatment  of  Chronic  Dysentery. — Chronic  dysentery  is  usually 
amebic  and  the  principles  of  treatment  are  about  the  same  as 
those  which  apply  to  acute  dysentery.  If  a  systematic  cure  is  to 
be  undertaken,  the  patient  must  be  kept  in  bed  for  several  weeks. 
The  diet  should  at  first  be  strict  and  sparing,  but  as  soon  as  pos- 
sible more  free  and  rich  in  caloric  value,  and  free  from  chemical 
and  mechanical  irritants.  When  it  becomes  possible  to  improve 
the  strength  and  the  general  state  of  nutrition,  a  distinct  advantage 
has  been  obtained.  Care  in  the  administration  of  milk  is  required. 
At  first  salicylic  acid  or  lime-water  should  be  added  (two  tablespoon- 
fuls  of  lime-water  to  a  quarter  of  a  liter  (|  pint)  of  milk  (page  176). 
Should  this  be  borne  well,  it  can  be  given  more  freely,  Kefir,  and 
particularly  yoghurt,  may  be  given  with  advantage  at  times.  Pure 
cultures  of  lactic  acid  bacilli  may  be  employed  with  benefit.  In 
some  cases  exclusive  systematic  milk  cures  are  very  useful,  but 
they  are  not  suitable  for  all  cases  (see  page  162).  Just  as  in  the 
case  of  acute  dysentery,  a  constipating  diet  (see  page  172)  should 
be  continued  for  an  indefinite  period  of  time. 


728  ULCERS  OF  THE  INTESTINE 

The  treatment  of  chronic  dysentery  by  medication  is  approxi- 
mately identical  with  that  of  acute  dysentery.  The  remedies 
mentioned  in  that  connection  must  be  also  considered  here,  espe- 
cially the  subcutaneous  injection  of  emetin  hydrochlorid.  When 
the  use  of  this  drug  is  not  feasible,  radix  ipecacuanha?  should  be 
given  in  large  doses  (2  Gm. — 30  grains).  Every  few  days  a  dose  of 
castor  oil  is  given  in  addition.  Olive  oil  in  large  doses,  two  table- 
spoonfuls  up  to  four  tablespoonfuls,  three  times  daily,  is  said  to 
act  well  in  some  cases. 

In  chronic  cases  the  lesions  are  found  to  be  limited  to  the  lower 
half  of  the  large  intestine — descending  colon,  sigmoid  flexure,  and 
rectum.  It  is  very  desirable  to  use  some  medication  that  will 
destroy  the  endameba  or  bacillus  and  at  the  same  time  heal  the 
ulcerated  surfaces.  Recently,  iodoform  enemata  have  been  recom- 
mended in  chronic  amebic  dysentery.  They  are  administered  while 
the  patient  is  in  either  the  knee-chest  or  the  left  lateral  posture, 
in  the  quantity  ot  250  Cc.  (|  pint)  of  an  iodoform  emulsion  con- 
taining 5  parts  of  iodoform  to  1000  cf  mucilage  of  gum  arabic.  The 
enema  must  be  given  high,  and  an  attempt  should  be  made  by 
massage  to  propel  it  as  far  up  into  the  colon  as  possible.  The 
iodoform  is  allowed  to  remain  within  the  bowel  fcr  ten  minutes,  and 
most  of  it  is  then  washed  out  by  two  separate  water  enemata. 
Poisoning  is  not  apt  to  occur,  but  in  some  individuals  having  an 
idiosyncrasy  toward  iodoform  a  severe  urticaria  may  make  its 
appearance  (see  page  236). 

A  combination  of  the  emetin  cure  with  the  iodoform  irrigation 
seems  to  be  the  most  effective  treatment.  Many  permanent 
recoveries  have  been  reported  from  this  procedure.  Bismuth 
subgallate  suspended  in  gum  arabic  or  oil  has  been  recommended 
instead  of  the  iodoform.  In  some  cases  tannic  acid  enteroclysis 
or  2-per-cent.  solution  of  sodium  salicylate  may  be  useful.  Quite 
recently  colonic  irrigation  with  petroleum  has  been  recommended: 
the  amount  specified  is  one  liter  (quart),  which  is  said  to  reach  as 
far  as  or  even  beyond  the  ileocecal  valve.  The  oil  is  retained  for 
ten  to  twenty  minutes. 

Many  cases,  however,  do  not  entirely  yield  to  treatment.  Such 
patients  have  to  be  very  cautious  all  the  time  not  to  commit  any 
indiscretion  in  either  hygiene  or  diet;  if  they  are  careful  it  is  possible 
for  them  to  avoid  relapses  and  lead  a  fairly  comfortable  existence. 
Repeated  drinking  cures  at  Carlsbad  are  to  be  highly  recommended. 

Surgical  Treatment. — When  no  cure  is  attained,  the  patients 
becoming  more  and  more  exhausted  as  the  weeks  pass  on,  surgical 
intervention  is  indicated.  It  is  impossible  to  say  with  absolute 
exactness  how  long  internal  treatment  ought  to  be  persevered  in; 
but  when  all  the  approved  methods  of  internal  treatment  have  on 
careful  trial  proved  ineffective,  it  is  certainly  proper  to  consider  the 


ACUTE  AND  CHRONIC  DYSENTERY 


729 


advisability  of  an  operation.  This  consists  in  the  establishment 
of  an  artificial  anus  at  the  cecum  (cecostomj  I  or  a1  the  appendix 
(appendicostomy),  with  irrigation  of  the  large  intestine  from  the 

fistula. 

Hale  White  was  the  first  to  suggest  surgical  treatment  for  chronic 
dysentery.  He  advocated  an  artificial  anus  on  the  right  side  of  the 
abdomen  to  make  possible  the  application  of  local  treatment  in 


5Xin  Incision 


Fig.  104. — Appendicostomy:  a,  skin;  b,  subcutaneous  fat;  c,  aponeurosis  of  external 
oblique;  d,  internal  oblique  and  transversalis;  e,  peritoneum;  /,  appendix.  (After 
Bidwell.) 

intractable  ulcerative  colitis.  Weir  utilized  the  appendix  as  a 
means  of  irrigation  and  the  introduction  of  medicaments  into  the 
large  intestine.  Willy  Meyer,  in  1902,  applied  the  term  "appendi- 
costomy" to  the  operation  devised  by  Weir  (Fig.  104).  The  most 
striking  result  of  this  operation  is  the  facility  with  which  the  irri- 
gation of  the  large  bowel  can  be  effected  (see  page  735). 


CHAPTER  XLIV. 

ULCERS  OF  THE  INTESTINE  (Continued). 

Catarrhal  and  Follicular  Ulcers — Ulcerative  Colitis — 
Ulcerative  Enteritis — Ulcerative  Sigmoiditis;  Stercoral 
or  Decubital  Ulcers. 

These  ulcers  were  referred  to  when  considering  acute  and  chronic 
intestinal  catarrh.  They  often  develop  from  superficial  abrasions, 
which  are  not  rare  in  intestinal  catarrh.  These  abrasions,  being 
irritated  chemically  and  infected  by  bacterial  growths,  may  by 
further  loss  of  substance  and  disintegration  of  tissue  be  converted 
into  ulcers.  Follicular  ulcers  may  originate  from  inflammation 
of  the  mucous  membrane  or  purulent  degeneration  and  disintegra- 
tion of  the  solitary  follicles.  They  are  principally  found  in  the 
colon.  Small  ulcers  frequently  occur  during  the  healing  process 
of  acute  and  chronic  catarrh,  and  require  careful  treatment  at 
this  time.  In  severe  intestinal  catarrh,  acute  or  chronic,  extensive 
ulceration  frequently  makes  its  appearance;  the  small  ulcers  may 
form  in  such  large  numbers  as  to  give  an  appearance  of  perfora- 
tion to  the  mucous  membrane,  or,  becoming  confluent,  may  develop 
into  large  ulcers,  the  result  being  a  most  serious  condition  of  ulcera- 
tive enteritis.  Such  degenerative  alterations  of  the  mucous  mem- 
brane of  the  bowel,  developed  from  a  catarrhal  affection,  are  found 
in  the  large  intestine  only.  Boas  designates  them  as  cases  of 
"colitis  chronica  ulcerosa,"  while  Rosenheim's  term  is  "colitis 
chronica  gravis."  These  terms  therefore  indicate  a  disease  of  the 
large  intestine  characterized  by  the  formation  of  numerous  exten- 
sive ulcers,  induced  usually  by  acute  or  chronic  inflammatory 
processes. 

Bacterial  invasions  of  various  kmds  probably  play  an  etiologic 
role,  since  the  Bacillus  coli,  staphylococci  and  streptococci  have 
been  found  present.  These  ulcers  are  not  associated  with  dysen- 
tery or  tuberculosis.  In  some  cases  it  would  appear  as  if  an 
achylia  gastrica  might  have  been  the  predisposing  cause,  while  in 
others  intestinal  diverticula  may  have  brought  about  the  disease. 

With  respect  to  pathologic  anatomy,  it  may  be  mentioned  that 
these  ulcers  are  often  located  in  the  sigmoid  flexure  (sigmoiditis) 
and  in  the  ampulla  recti,  though  they  may  be  found  higher  up  in 
any  part  of  the  large  intestine.  In  dimensions  the  ulcers  vary 
from  the  size  of  a  pea  to  that  of  a  silver  dollar.  In  lighter  cases 
there  mav  be  erosions  instead  of  well-defined  ulcers.     There  may 


CATARRHAL  AND  FOLLICULAR  ULCERS  731 

be  areas  <>f  denuded  patches  or  streaks  over  the  surface  of  the 

mucosa.  Here  and  there  are  scattered  smaller  or  larger  islands  of 
discolored  hyperplastic  mucous  membrane.  In  the  region  of  these 
areas  of  denudation  the  mucosa  is  fairly  smooth  to  granular. 

Symptoms. — The  disease  frequently  commences  with  an  acute 
attack,  which  apparently  subsides  within  eight  to  fourteen  days 
and  is  succeeded  by  a  chronic  stage  of  ulcerative  colitis.  This 
may  continue  for  years,  interrupted  now  and  then  by  violent  acute 
exacerbations  of  the  symptoms.  The  first  attack  of  an  acute 
colitis  is  ushered  in  by  fever,  lassitude,  headache,  and  pains  in  the 
limbs;  the  stools  are  diarrheic  in  character,  containing  mucus, 
blood  and  pus.  The  abdomen  is  rarely  distended.  The  descend- 
ing colon  and  the  sigmoid  flexure  are  painful  to  pressure,  and 
resistance  may  be  encountered  on  palpation.  This  acute  condition 
rarely  ends  in  complete  recovery.  Although  the  febrile  symptoms 
subside  and  the  stools  become  more  solid  and  less  frequent,  the 
healing  process  is  not  complete;  on  the  contrary  the  condition 
passes  into  a  chronic  stage.  During  this  latter  period  the  patient 
may  feel  comparatively  well  so  that  he  can  follow  his  usual  employ- 
ment free  from  all  troublesome  symptoms.  The  stool  is,  however, 
slightly  more  frequent  than  normal,  wdiile  blood,  mucus  and  pus 
are  always  present  in  it.  Insignificant  causes,  as  errors  in  diet, 
cold  drinks,  and  exposure,  may  induce  relapses  and  acute  attacks  of 
great  frequency,  gradually  reducing  the  strength  of  the  patient 
considerably.  It  is  always  very  difficult  to  accomplish  a  complete 
cure  of  a  well-established  chronic  case,  but  it  is  frequently  possible 
to  bring  about  improvement  and  periods  of  rest.  Frequent  attacks 
and  the  continuous  loss  of  blood  and  secretions  are  apt  to  reduce  the 
patient's  vitality  to  so  low  an  ebb  as  to  seriously  imperil  life  itself. 

Ulcerative  enteritis  may  be  complicated  by  profuse  hemorrhages. 
Perforation  is  not  of  frequent  occurrence,  for  exudations  and 
adhesions  are  usually  formed  around  the  ulcerated  gut,  providing 
an  efficient  barrier  against  it.  Serous  and  purulent  exudates  often 
encircle  the  diseased  intestine,  especially  in  the  left  inguinal  region 
and  around  the  sigmoid  flexure.  This  condition  is  termed  perisig- 
moiditis (see  Chapter  LI);  it  is  characterized  by  a  hard,  cylindric, 
painful  tumor  in  the  left  iliac  fossa,  frequently  running  a  course 
similar  to  appendicitis  with  the  formation  of  exudates  and  abscesses. 
In  severe  cases  there  occasionally  results  a  general  systemic  infection 
accompanied  by  high  fever,  chills,  swelling  of  the  joints,  endocarditis 
and  subcutaneous  hemorrhages.  This  morbid  process  is  sometimes 
complicated  by  the  formation  of  a  stricture  in  the  affected  portion 
of  the  gut,  due  to  cicatricial  contraction.  Taking  it  all  in  all, 
ulcerative  enteritis  is  therefore  a  severe  affection,  with  a  rather 
serious  prognostic  aspect. 

Diagnosis. — Considering  the  foregoing,  the  diagnosis  is  not 
difficult.     The  demonstration   of  mucus,   pus  and   blood   in  the 


732  ULCERS  OF  THE  INTESTINE 

diarrheic  stools,  with  the  absence  of  dysentery  bacilli,  endamebse 
and  tubercle  bacilli,  is  a  decisive  point. 

Treatment. — In  the  first  place  it  is  essential  that  the  diseased 
bowel  be  placed  at  rest.  This  end  is  partly  attained  by  keeping 
the  patient  continuously  in  bed  for  a  long  time,  a  procedure  that 
must  be  insisted  upon  while  the  case  is  acute,  and  that  is  also 
necessary  in  the  chronic  stage  of  the  disease  in  order  that  sys- 
tematic treatment  may  be  followed.  The  entire  treatment  is  more 
satisfactory  when  carried  out  in  an  institution.  Appropriate  diet 
will  assist  in  keeping  the  intestine  at  rest.  The  food  should  be 
both  chemically  and  mechanically  non-irritating,  semiliquid,  and 
at  the  same  time  as  rich  in  caloric  power  as  possible;  it  must  also 
be  distinctly  antiputrefactive.  Details  on  these  points  are  fully 
considered  in  Chapter  VII  on  Diet.  In  the  chronic  stage  the  diet 
need  not  necessarily  consist  entirely  of  soup,  but  may  be  com- 
posed of  a  mixture  containing  meat  and  vegetables,  always  finely 
subdivided  or  as  purees.  Caution  is  required  with  regard  to 
milk;  trials  should  be  carefully  made  to  ascertain  whether  it  agrees 
with  the  patient.  Yoghurt  and  three-day  kefir  are  often  very 
serviceable.  Astringent  foods  should  be  given  freely;  the  same 
holds  good  for  fat,  and  in  some  cases  artificial  nutritive  prepara- 
tions are  advisable.  In  those  rare  cases  in  which  constipation 
prevails,  fruit  sauces,  apple  jam  and  honey  should  be  added  to 
the  diet. 

Opium  places  the  intestine  more  completely  at  rest  than  the 
above  diet,  and  it  is  difficult  to  do  without  it.  It  inhibits  peristalsis, 
diminishes  the  pains,  and  is  effective  when  given  either  by  mouth 
or  by  rectum.  A  good  substitute  for  opium  is  pantopon  (see  page 
275).  If  there  are  pains  and  tenesmus,  suppositories  of  extract 
of  belladonna  or  eumydrin,  0.0005  Gm.  (y^o  grain),  should  be 
given.  Other  remedies,  which  are  suitable  for  oral  administration, 
are  subgallate  of  bismuth,  tincture  of  calumba,  and  compound  tinct- 
ure of  gambir.  Rosenheim  recommends  calomel  in  the  acute 
stages,  giving  doses  of  0.03  Gm.  (§  grain)  twelve  times  daily  for 
three  successive  days.    Mercury  acts  especially  well  in  some  cases. 

Dunn  reports  that  in  the  Berkshire  Asylum,  Wallingford,  the 
treatment  of  ulcerative  colitis  by  creosote  and  oleum  morrhuse 
has  given  such  good  results  that  it  is  now  exclusively  utilized.  He 
has  no  hesitation  in  saying  that  it  relieves  the  symptoms  more 
quickly  and  shortens  the  course  of  the  disease  more  effectually 
than  any  other  treatment;  moreover,  the  mortality  has  been  less 
since  this  method  was  adopted.  The  dosage  is  as  follows:  Creo- 
sote 0.2  Gm.  (3  grains)  in  oleum  morrhuse  4  Cc.  (5j),  three  times 
the  first  day  of  the  disease,  castor  oil  having  been  previously 
administered.  The  quantities  specified  are  doubled  on  the  second 
day  and  increased  in  the  same  mathematical  ratio  daily  until  on 
the  fourth  day  the  patient  is  taking  creosote  0.75  Gm.  (12  grains) 


CATARRHAL  AND  FOLLICl  LAR  ULCERS  7:;:; 

and  oleum  mdrrhuse  15  Cc.  (Sss)  three  times  a  day.    This  dose  is 
continued  until  the  termination  of  the  disorder. 

Local  treatment  of  the  diseased  bowel  is  appropriate  and  effective. 
h  i  onsists  of  a  combination  of  lavage,  colonic  irrigation,  and  "dry 
treatment"  (see  page  1237).  Colonic  irrigation  is  given  in  the 
manner  described  in  Chapter  XI.  With  the  patient  in  the  dorsal 
or  left  lateral  position,  the  rectum  is  first  cleansed  with  a  moderate 
quantity  of  warm  water,  after  which  the  water  is  allowed  to  escape. 
Only  after  this  thorough  cleansing  should  irrigations  be  allowed  to 
traverse  the  higher  sections  of  the  diseased  gut.  This  method 
prevents  the  possibility  of  inflammatory  products  being  carried 
up  the  bowel.  Carlsbad  water  or  0.5-  to  1-per-cent.  solutions  of 
bicarbonate  of  sodium  are  used  for  these  irrigations,  and  they  are 
allowed  to  immediately  escape.  Medicated  liquids,  such  as  potas- 
sium permanganate  1 :  1000,  boric  acid  1 :  100,  ichthyol  1 :  100,  hydro- 
gen peroxid  (3  per  cent.),  solutions  of  gelatin,  suspensions  of  bis- 
muth subnitrate  or  bismuth  subgallate  in  water  or  mucilaginous 
vehicles,  are  allowed  to  flow  into  the  rectum  and  retained  if  possible 
for  ten  to  fifteen  minutes.  These  irrigations  are  to  be  made  daily. 
Their  effect  is  ascertained  by  means  of  the  proctoscope  and  by 
microscopic  examination  of  the  discharges. 


Fig.  105. — Wales  bougie. 

Matthews'  treatment  is  as  follows:  A  Wales  bougie  (Fig.  105) 
is  passed  into  the  sigmoid  flexure,  and  at  least  a  half-gallon  of 
tepid  water  containing  one  ounce  of  a  saturated  solution  of  boric 
acid  injected.  The  patient  retains  this  for  twenty  to  thirty  minutes 
and  is  then  allowed  to  pass  it.  This  injection  is  repeated  each 
morning — after  the  bowels  have  moved — for  a  week.  Then  an 
antiseptic  astringent  wash  is  used — one  tablespoonful  of  pinus 
canadensis  to  a  pint  of  tepid  water,  thrown  into  the  sigmoid  flexure 
daily,  and  allowed  to  remain  until  the  patient  is  forced  to  evacuate 
it;  repeat  for  six  to  eight  days.  After  the  second  week  an  oil 
preparation  consisting  of  sweet  almond  oil  1  pint,  iodoform  1 
dram,  subnitrate  of  bismuth  \  ounce,  is  most  serviceable.  This 
preparation  should  be  shaken  each  time;  one  ounce  of  it  to  a  tea- 
cupful  of  warm  water  is  deposited  in  the  sigmoid  flexure,  through 
the  Wales  bougie,  each  night  at  bedtime. 

In  case  this  treatment,  which  must  be  persisted  in  for  weeks 
and  months,  and  then  repeated,  does  not  accomplish  the  desired 
result,  it  will  be  advisable  to  give  the  "dry  treatment"  a  trial. 
This  treatment  has  been  advanced  by  Rosenberg  (see  page  237) .  In 
order  to  secure  satisfactory  results  it  is  absolutely  necessary  to 


734  ULCERS  OF  THE  INTESTINE 

ascertain  exactly  how  far  the  disease  process  has  spread.  Success 
can  seldom  be  attained  unless  it  is  possible  to  reach  far  beyond  the 
upper  boundary  of  the  disease  and  to  subject  the  affected  area  to 
treatment  from  above  downward.  The  opposite  route  must  never 
be  taken.  The  "dry  treatment"  consists  primarily  in  the  appli- 
cation of  powder  to  the  diseased  mucous  membrane,  in  order  to 
permit  the  medication  to  act  directly  for  a  longer  space  of  time 
than  would  otherwise  be  possible.  It  is,  of  course,  necessary  that 
the  nmcous  membrane  be  previously  thoroughly  cleansed;  and  this 
is  accomplished  most  satisfactorily  by  an  enema  of  bicarbonate  of 
sodium,  0.5  to  1  per  cent,  in  water.  Six  to  eight  hours  later  an 
attempt  should  be  made  to  reach  the  upper  boundary  of  the  inflam- 
mation with  the  sigmoidoscope  (Fig.  46),  and  powder  should  be 
applied  with  the  powder-blower  (Figs.  48  and  49)  until  all  of  the 
mucous  membrane  visible  to  the  eye  is  thoroughly  covered.  The 
sigmoidoscope  is  then  withdrawn  a  few  inches,  more  powder  applied 
to  the  new  section  of  mucous  membrane  disclosed,  and  so  on  until 
the  anus  is  reached.  Areas  which  are  either  too  moist  or  covered 
with  mucus  should  be  first  thoroughly  mopped  and  dried  with 
absorbent  cotton.  The  ulcers  may  be  cleansed  with  a  swab  satu- 
rated with  peroxid  of  hydrogen;  the  generated  froth  forming  a 
layer  is  carefully  wiped  away,  and  the  powder  is  then  applied. 
The  ulcers  may  also  be  cauterized  with  nitrate-of-silver  solution; 
the  excess  must  be  neutralized  with  a  solution  of  common  salt. 
Rosenberg  recommends  the  following  mixture  for  dusting  purposes : 

Gm.  or  Cc. 

E, — Acidi  tannici 15—30 10  Bss-j 

Magnesii  oxidi 100 10  §iij 

Misce. 

Sig. — Apply  as  dusting  powder. 

To  which  may  be  added,  when  desirable,  xeroform,  bismuth 
subgallate,  or  zinc  oxide.  The  application  of  xeroform  and  sub- 
gallate  of  bismuth,  equal  parts,  is  often  followed  by  excellent  results 
in  ulcerative  lesions.  The  following  mixture  may  be  used  for 
dusting : 

Gm.  or  Cc. 

1$ — Bismuthi  subgallatis, 

Acidi  tannici aa       10 10  oiiss 

Sodii  chloridi 5|0  3j 

Misce. 

Sig. — Apply  as  dusting  powder. 

The  sodium  chlorid  in  the  above  prescription  is  said  to  produce 
reversed  peristaltic  movements  by  which  the  powder  is  carried  as 
far  up  as  possible. 


CATARRHAL  AND  FOLLICULAR  ULCERS  7 '35 

Calomel  adheres  well  t<>  the  intestinal  mucosa  and  cannot  be 
easily  dislodged.  It  can  be  dusted  on  the  mucous  membrane  with 
the  powder-blower  (Figs.  48  and  49)  through  the  proctoscope.  It 
is  a  non-irritant  antiseptic  and  may  he  applied  to  the  sensitive 
mucosa  without  inducing  pain.  Systemic  disturbances  do  not  occur 
even  if  it  is  used  daily. 

Ulcerative  colitis  is  the  very  type  of  disease  which  should  yield 
to  vaccine  treatment.  The  site  of  infection  is  localized,  there  is  no 
general  infection,  and  the  symptoms  are  mainly  local,  though 
partly  toxemic.  The  necessity  for  bacterial  vaccine  treatment 
holds  good  whether  the  primary  organism  concerned  should  ulti- 
mately prove  to  belong  to  the  dysenteric,  the  paratyphoid,  the 
coli  or  the  pyogenic  group.  Best  results  are  obtained  after  the 
history  of  the  disease  is  understood  and  the  germ  is  isolated  so 
that  an  autogenous  vaccine  can  be  made.  Many  cases  have  been 
examined  bacteriologically  by  Sir  Almroth  E.  Wright,  and  only  the 
streptococci  and  the  Bacillus  coli  were  found.  It  would  seem  from 
this  that  a  polyvalent  stock  vaccine  consisting  of  streptococci  and 
colon  bacilli  could  be  tried  with  the  other  methods  of  treatment. 
The  injection  of  a  polyvalent  vaccine,  30,000,000  streptococci  and 
50,000,000  colon  bacilli,  once  a  wreek,  is  a  safe  procedure  (see 
page  506). 

Surgical  Treatment. — Should  none  of  these  measures  prove  satis- 
factory, the  ulcers  persisting  in  spite  of  everything,  and  the  patients 
becoming  emaciated  and  severely  anemic,  the  operative  method 
remains,  by  which  many  cases  have  been  successfully  treated. 

Active  surgical  treatment  is  necessary  in  cases  that  do  not  respond 
to  internal  treatment.  The  large  bowel  must  be  kept  empty  and 
at  rest.  A  good-sized  artificial  opening  is  made  in  the  cecum,  or 
the  appendix  is  fixed  to  the  abdominal  wall  and  opened  (Fig.  104). 
Intestinal  contents  are  in  this  way  diverted  from  the  ulcerated 
colon,  which  is  at  the  same  time  put  at  rest  and  under  the  best 
conditions  for  healing.  Through  the  opening  thus  made  the 
inflamed  and  ulcerated  bowel  can  be  daily  irrigated.  The  cecostomy 
or  appendicostomy  opening  is  easily  closed. 

The  chief  benefit  secured  by  this  operation  is  that  the  large 
intestine  is  placed  at  absolute  rest.  It  is  clear  that  the  principal 
cause  of  the  frequent  relapses  is  the  constant  irritation  of  the 
mucous  membrane  by  the  steady  passage  over  it  of  decomposed 
intestinal  contents,  so  that  it  never  has  any  rest.  The  establish- 
ment of  an  artificial  anus  through  which  the  stools  are  passed 
without  reaching  the  large  intestine,  changing  the  course  of  the 
fecal  current,  is  a  most  urgent  indication.  The  establishment  of 
the  anus  preternaturalis  either  at  the  ileum  or  at  the  cecum  is 
decidedly  the  most  appropriate  operation  (see  page  729). 


736  ULCERS  OF  THE  INTESTINE 

STERCORAL  OR  DECUBITAL  ULCERS. 

These  ulcers  appear  at  those  spots  which  are  most  exposed 
to  the  pressure  of  the  fecal  mass,  that  is  to  say  the  cecum,  the 
splenic  and  sigmoid  flexures,  and  the  rectum.  They  do  not  occur 
when  the  bowel  movements  are  quite  normal,  but  only  when  the 
fecal  matter  stagnates,  as  in  constipation  and  stenosis,  when  they 
may  become  extensive  and  deep,  penetrating  the  mucous  membrane. 
Occasionally  an  inflammation  of  the  cecum,  typhlitis  stercoralis, 
develops  from  such  ulcers.  Stercoral  ulcers  are  not  very  frequent. 
In  rare  cases  they  are  followed  by  strictures  of  the  gut  in  consequence 
of  cicatricial  contracture  during  the  healing  process. 


CHAPTER  XLV. 
ULCERS  OF  THE  INTESTINE  (Continued). 
Tuberculosis;  Syphilis;  Embolus;  Thrombus. 

TUBERCULAR  INTESTINAL  ULCERS. 

This  form  of  intestinal  ulceration  is  more  frequent  than  any 
other.  Distinction  is  made  between  primary  and  secondary  tuber- 
culosis of  the  intestine.  The  occurrence  of  primary  intestinal 
tuberculosis,  running  its  course  in  patients  otherwise  free  from 
tuberculosis,  is  now  considered  well  established.  It  occurs  very 
rarely  in  adults,  more  frequently  in  infants  and  in  very  young 
children.  It  is  due  to  the  ingestion  of  food  containing  tubercle 
bacilli,  as  infected  milk,  or  meat  from  tuberculous  animals.  Secon- 
dary intestinal  tuberculosis,  on  the  other  hand,  is  an  exceedingly 
common  disease  and  is  found  in  approximately  50  to  60  per  cent, 
of  all  patients  affected  with  tuberculosis  of  the  lungs.  Its  develop- 
ment must  be  ascribed  to  the  swallowing  of  sputum  containing  the 
tubercle  bacilli. 

The  bacillus  of  tuberculosis  is  not  appreciably  modified  by  the 
action  of  the  gastric  juice,  either  in  form  or  staining  reactions; 
the  greater  part  of  the  elements  which  constitute  the  bacterial 
cell  are  not  susceptible  of  digestion  by  the  gastric  juice,  toward 
which  the  cells  art  in  the  same  manner  as  cellulose  and  nuclein. 
This  latter  body,  indeed,  would  appear  to  enter  largely  into  the 
composition  of  the  bacterial  cell.  In  laboratory  experiments  the 
tubercle  bacillus  has  retained  its  vitality  or  its  virulence  for  thirty- 
six  hours  in  contact  with  the  gastric  juice.  Normal  gastric  juice, 
therefore,  does  not  destroy  the  tubercle  bacilli. 

The  favorite  location  of  these  ulcers  is  the  lower  part  of  the  ileum 
and  the  cecum;  they  are  also  frequently  found  in  the  jejunum 
and  in  the  entire  length  of  the  large  intestine  down  to  the  rectum. 
They  have  their  starting  point  in  the  miliary  tubercles  which  are 
found  in  the  solitary  follicles  and  in  Peyer's  patches.  The  ulcers 
are  of  all  sizes,  and  may  be  superficial  or  deep,  penetrating  to  or 
even  through  the  serous  coat.  Frequently  whole  regions  of  the 
mucous  membrane  are  uniformly  ulcerated;  this  is  particularly 
true  of  the  cecum.  The  mucous  membrane  contiguous  to  the 
ulcers  is  often  in  a  condition  of  chronic  catarrh  of  varying  intensity; 
occasionally,  however,  it  is  perfectly  healthy  between  the  ulcers, 
even  though  there  may  be  many  in  the  immediate  vicinity.  In 
47 


738  ULCERS  OF  THE  INTESTINE 

■severe  cases  of  phthisis  the  mucous  membrane  of  the  intestine 
shows  simultaneously  extensive  amyloid  degeneration.  The  ulcers 
may  manifest  themselves  subjectively  by  pain,  which  of  itself 
does  not  have  any  special  characteristics.  Objectively  pain  on 
pressure  is  occasionally  found,  particularly  in  the  umbilical  region, 
and  the  abdomen  may  be  slightly  distended. 

Diagnosis. — The  diagnosis  is  made  principally  from  the  condition 
of  the  stools.  Frequent  attacks  of  diarrhea  are  often  the  first 
symptom  of  intestinal  tuberculosis.  These  are  particularly  liable 
to  occur  cciincidently  with  catarrh  of  the  "mucous  membrane  of 
the  small  intestine.  The  diarrhea  is  probably  due  to  an  irritation 
of  the  nerve  fibrils  exposed  by  the  deeply  penetrating  ulceration. 
The  test-diet  stool  presents  most  varied  appearances,  depending 
upon  the  condition  of  the  digestive  tract.  Aside  from  its  diarrheic 
character,  there  are  found  in  the  feces  the  signs  of  disturbance  of 
digestion  in  the  small  intestine,  food  remnants,  mucus,  bilirubin, 
decomposition  products,  and  with  concurrent  catarrh  of  the  colon 
correspondingly  large  flakes  of  mucus.  Blood  will  be  found  in  the 
form  of  occult  hemorrhages,  bloody  mucus,  or  pure  blood  mixed 
with  the  fecal  matter  and  visible  to  the  naked  eye.  The  presence 
of  pus  in  the  feces  is  of  great  importance;  the  pus  can  be  seen 
with  the  unaided  eye  when  the  fecal  matter  is  inspected  after  it 
has  been  finely  triturated  and  placed  on  a  black  background;  it 
appears  in  the  form  of  small  points  the  size  of  a  pinhead,  rounded 
and  whitish  yellow  in  color  (see  Chapter  IV).  In  consequence 
of  the  admixture  of  blood,  pus  and  serum,  these  stools  always 
decompose.  Under  certain  circumstances  it  is  possible  to  decide 
whether  the  large  intestine  alone  is  affected,  or  whether  the  small 
intestine  participates  in  the  morbid  process.  Occasionally  there 
are  cases  in  which  firmly  formed  stools  are  passed,  or  in  which  even 
constipation  prevails,  notwithstanding  the  existence  of  numerous 
ulcers.  When  making  a  more  exact  analysis  of  these  cases,  how- 
ever, with  particular  regard  to  the  feces,  the  presence  of  inflam- 
matory products  of  the  intestinal  walls  will  not  fail  to  be  demon- 
strable. On  the  other  hand,  there  may  be  the  most  marked  diarrhea 
although  only  a  few  or  quite  superficial  ulcers  are  present.  The 
demonstration  of  tubercle  bacilli  in  the  feces,  especially  in  the 
mucus  and  the  little  lumps  of  pus,  is  important;  but  it  affords  proof 
of  the  existence  of  primary  tuberculosis  of  the  intestine  only  when 
the  swallowing  of  sputa  containing  tubercle  bacilli  can  be  posi- 
tively excluded.  The  von  Pirquet  or  the  Calmette  reaction  will 
often  assist  in  the  diagnosis.  The  complications  which  may  occur 
are:  perforations,  local  and  general  peritonitis,  and  more  rarely 
severe  hemorrhage. 

Prognosis. — The  prognosis  of  intestinal  tuberculosis  is  always 
bad.     Some  few  ulcers  may  occasionally  heal.     Any  case  of  tuber- 


TUBERCl  LAR  INTESTINAL  ULCERS  739 

culosis,  however,  that  has  become  fairly  established  never  recovers, 
and  a  fatal  termination  occurs  sooner  or  later. 

Treatment.  The  treatment  of  intestinal  tuberculosis  is  there- 
fore difficult  and  disappointing.  When  diarrhea  exists,  attempts 
should  he  made  to  put  the  intestine  at  rest  first,  by  rest  in  bed; 
and  second,  hy  dietetic  measures.  The  diet  must  he  regulated  most 
carefully,  especially  when  it  can  lie  proved  from  an  examination 
of  the  stools  that  there  is  catarrh  of  the  small  intestine.  In  such 
cases  the  diet  furnished  should  he  absolutely  bland,  non-irritating, 
and  not  liable  to  decomposition.  When  milk  can  he  tolerated  it 
should  always  he  given,  with  the  addition  of  salicylic  acid.  Kefir 
and  yoghurt  are  likewise  advisable.  Adolf  Schmidt  advises  for 
cases  in  which  (as  ascertained  by  an  examination  of  the  stools) 
the  symptoms  of  intestinal  catarrh  are  receding,  in  which  the  small 
intestine  is  not  involved,  in  which  normal  stools  are  evacuated, 
or  in  which  constipation  exists,  that  it  is  not  necessary  to  be  over- 
careful  in  respect  to  the  diet,  but  that  the  dietary  prescriptions 
should  be  frequently  altered  and  a  somewhat  coarse  diet  allowed. 
Experience  proves  that  a  comparatively  coarse  diet  is  often  well 
borne  while  a  bland  diet  is  followed  by  diarrhea.  In  such  cases, 
therefore,  the  motto  must  be:    Experiment  and  individualize. 

Hyperalimentation  (see  page  569)  is  the  dietary  treatment  of 
tuberculosis.  Food  representing  the  greatest  caloric  value  should 
be  given.  The  dietetic  treatment  should  be  carefully  carried  out, 
as  described  in  Chapter  YII. 

Medicinal  treatment  may  also  be  employed.  Preparations  suit- 
able for  this  purpose  are:  Milk-somatose,  the  calcium  preparations 
either  alone  or  in  combination  with  bismuth  subnitrate,  bismuth 
betanaphthol,  and  bismuth  subgallate.  Ulcers  of  the  large  intestine 
may  in  some  instances  be  treated  locally  by  medicated  irrigations 
and  enemata  of  bismuth  subnitrate  and  bismuth  subgallate  sus- 
pensions. Here,  however,  great  caution  is  necessary,  as  the  dis- 
tention of  the  diseased  gut  by  these  enemata  may  be  alarming. 
An  oil  enema  is  prepared  by  thoroughly  rubbing  up  bismuth  sub- 
nitrate in  a  mortar  with  lukewarm  olive  oil.  Occasionally  we  may 
succeed  in  ameliorating  or  even  healing  tuberculous  ulcers  of  the 
rectum  and  colon  by  bismuth-oil  enemata. 

In  tenesmus  and  pains,  opium  and  extract  of  belladonna  may 
be  administered  in  the  form  of  suppositories.  Intestinal  astringents 
(see  Chapter  XIV)  such  as  tannoform,  tannalbin,  tannyl,  tannigen, 
and  tannopin  are  also  advocated.  In  the  presence  of  decompo- 
sition, enteric-coated  pills  of  menthol  or  creosote  can  be  given. 
Constipation  is  to  be  relieved  by  oil  enemata  (see  page  223). 

Symptomatic  treatment  of  the  intestinal  derangements  requires 
careful  consideration,  and  will  oftentimes  of  itself  accomplish  a 
great  deal.  Moist  or  dry  heat  should  be  freely  applied  to  the 
abdomen  for  the  relief  of  pains  and  diarrhea. 


740  ULCERS  OF  THE  INTESTINE 

Concerning  the  specific  treatment  of  intestinal  tuberculosis  by 
tuberculin,  Hemmeter  says  there  is  no  doubt  that  a  number  of 
patients  have  been  cured  by  this  means,  cautiously  employed.  He 
has  personally  studied  the  healing  of  a  tuberculous  rectal  ulcer 
under  the  influence  of  tuberculin;  nevertheless  he  does  not  recom- 
mend the  systematic  employment  of  tuberculin  in  the  treatment  of 
tuberculous  intestinal  ulcers,,  enteritis,  or  cecal  tumor,  because 
this  form  of  treatment  has  not  yet  been  satisfactorily  tested  for 
intestinal  diseases,  and  also  because  of  the  undesirable  effects 
tuberculin  occasionally  produces  on  other  organs  which  demand 
consideration.  Good  results  with  tuberculin  imply  an  early 
institution  of  the  treatment  and  the  use  of  very  small  doses. 

TUBERCULOSIS  OF  THE  CECUM. 

The  tuberculous  tumor  of  the  cecum  develops  at  the  site  of 
tuberculous  ulcers  of  the  cecum .  The  ulcers  induce  inflammatory 
infiltration  and  thickening  of  the  parietes  of  the  cecum,  with  peri- 
cecal inflammation  and  the  formation  of  adhesions.  They  may  also 
lead  to  cicatricial  contraction,  which  may  gradually  produce  a 
progressive  stenosis  of  the  intestinal  canal  and  of  the  ileocecal 
valve.  The  stenosis  favors  the  development  of  hypertrophy  of 
the  intestinal  wall.  Thus  a  tumor  is  being  gradually  developed 
which  may  ajssume  large  proportions  and  which  is  most  intimately 
adherent  to  the  adjoining  structures  by  inflammatory  exudations. 
The  development  of  such  tumors,  particularly  in  the  cecum,  is 
favored  by  the  fact  that  tubercular  material  may  easily  accumulate 
there.  Both  sexes  are  affected  in  about  the  same  ratio.  Tubercu- 
losis of  the  cecum  is  most  frequent  between  the  ages  of  twenty 
and  forty. 

Symptoms. — The  commencement  of  the  disease  is  usually  insidi- 
ous. At  first  diarrhea  alternates  with  conditions  of  constipation. 
After  that  follow  most  gradually  symptoms  of  stenosis,  colicky 
pains,  visible  peristalsis,  and  vomiting.  Finally  nutrition  is  greatly 
interfered  with,  resulting  in  fever  and  cachexia.  Objectively  the 
disease  is  recognized  by  the  presence  of  the  tumor  in  the  cecal 
region,  differing  from  carcinoma  in  the  same  locality  by  being 
more  elongated.  The  differential  diagnosis  between  tuberculosis 
and  carcinoma  of  the  cecum  is  frequently  very  difficult. 

The  appearance  of  blood,  pus  and  tubercle  bacilli  in  the  stools 
is  of  great  importance.  The  diagnosis  is  also  aided  by  the  fact 
that  most  of  the  patients  show  signs  of  incipient  phthisis  of  the 
lungs.  The  diazo-reaction  is  usually  positive  in  intestinal  tuber- 
culosis. The  bowel  may  become  completely  occluded  as  the 
disease  progresses.  Other  complications  are:  abscesses  in  and 
around  the  tumor,  which  may  perforate  to  the  outside  (sponta- 
neous formation  of  an  artificial  anus),  or  rupture  into  the  peritoneal 


EMBOLIC  AND  THROMBOTIC  ULCERS  711 

cavity.  The  course  of  the  disease  may  be  quite  protracted.  Cajses 
of  two  or  three  years'  duration  have  been  observed. 

Appendicitis  with  induration  may  be  mistaken  for  tuberculosis 
of  the  cecum.  On  the  other  hand,  tuberculosis  of  the  cecum  may 
be  complicated  by  appendicitis  (see  page  767). 

Treatment. — The  only  treatment  that  oilers  any  chance  for 
recovery  is  surgical.  The  results  after  operation  are  not  at  nil 
bad,  although  the  patients  usually  continue  to  suffer  for  a  long 
time  and  they  generally  succumb  sooner  or  later  to  their  lung 
infection.  The  mortality  after  operation  is  about  the  same,  whether 
an  entero-anastomosis  with  exclusion  of  the  diseased  gut  or  a  total 
extirpation  of  the  tumor  has  been  done.  The  dangers  of  the 
operation  per  se  are  not  excessive,  the  mortality  amounting  to  about 
10  per  cent. 

SYPHILITIC  ULCERS  OF  THE  INTESTINE. 

Syphilis  of  the  intestine  presents  itself  in  the  form  of  ulcers 
which  make  their  appearance  quite  rarely  in  the  small  and  more 
rarely  still  in  the  large  intestine.  Intestinal  syphilis  occurs  most 
frequently  in  the  rectum  (see  page  843,  "Ulcers  of  the  Rectum"). 
The  ulcers  develop  from  the  disintegration  of  gummata  which  are 
situated  in  the  mucosa  and  submucosa.  At  first  flat,  bead-shaped 
gummatous  neoplasms  make  their  appearance,  and  as  these  dis- 
integrate an  ulcer  results.  The  ulcers  are  sharply  circumscribed, 
having  a  yellowish,  fatty  base,  and  extend  more  on  the  surface 
than  in  depth.     Stenoses  often  result  after  cicatrization. 

Treatment. — When  it  has  been  possible  to  establish  a  diagnosis, 
the  treatment  must,  of  course,  be  specific.  But  generally  it  is 
only  possible  to  make  a  diagnosis  during  an  operation  which  has 
become  imperative  in  consequence  of  the  stenotic  symptoms 
(see  page  533) . 

EMBOLIC  AND  THROMBOTIC  ULCERS. 

These  ulcers  owe  their  existence  to  embolisms  in  some  small 
branches  of  the  mesenteric  artery  due  to  an  endocarditis,  and  to 
atheromatous  changes  in  the  larger  arteries.  A  small  hemorrhagic 
infarct  develops  after  the  embolism,  and  this  becomes  necrotic, 
causing  an  ulcer.  This  variety  of  ulcer  is  met  with  most  frequently 
in  the  small  intestine,  and  is  rare  in  the  colon.  The  size  of  the 
ulcers  is  variable  and  depends  on  the  hemorrhagic  mfarct.  In 
severe  cases  with  extensive  infarcts  the  necrotic  areas  may  become 
large  and  the  ulcerations  so  deep  as  to  perforate  into  the  peritoneal 
cavity.  When  the  embolus  is  septic,  small  abscesses  may  develop 
in  the  submucosa,  which  again  give  rise  to  ulcerations.  Thrombotic 
abscesses  develop  in  the  same  manner  when  thromboses  are  formed 
in  the  inferior  mesenteric  vein. 


CHAPTER  XLVL 
OBSTRUCTION  OF  THE  INTESTINE. 

Ileus— Intestinal  Occlusion— Miserere — Passio  Iliaco. 

In  obstruction  of  the  bowels  the  intestinal  canal  is  entirely 
blocked  and  the  normal  passage  of  the  feces  is  completely  arrested. 
Ileus  may  appear  suddenfy,  or  it  may  develop  slowly,  according 
to  the  nature  of  the  obstruction,  until  complete  closure  results. 

Occlusion  of  the  intestine  is  always  a  very  serious  disease  and 
terminates  invariably  in  death  unless  the  canal  is  reopened,  either 
spontaneously,  surgically,  or  by  internal  medication. 

Etiology. — The  etiology  of  ileus  is  very  extensive.  The  following 
causes  have  been  observed: 

I.  External  Ileus. — (1)  Angulations,  kinks,  membranes,  occlu- 
sions due  to  peritoneal  adhesions,  omental  bands  and  caseating 
glands,  incarcerations  into  preexisting  peritoneal  apertures  and  clefts, 
as  Meckel's  diverticulum,  or  external  and  internal  hernias  (of  special 
importance  is  hernia  diaphragmatica) .  Meckel's  diverticulum, 
usually  from  three  to  ten  centimeters  long,  with  its  extremity  free 
in  the  abdominal  cavity,  resembles  a  ringer  in  size  and  shape; 
it  is  always  found  singly,  above  the  ileocecal  valve,  opposite 
the  insertion  of  the  mesentery,  being  a  remnant  of  the  embry- 
onal omphalomesenteric  duct.  These  forms  of  ileus,  because  of 
anatomic  situation,  usually  affect  the  ileum.  Incarceration  of  a 
retroperitoneal  hernia  may  cause  ileus.  A  Trietz  hernia  must 
not  be  overlooked;  this  consists  of  a  tumor  of  gas  involving  a 
part  or  the  whole  of  the  small  intestine,  although  the  latter  may 
be  adherent  to  the  stomach  and  colon.  Of  diagnostic  importance 
is  the  commencement  of  the  disease  during  perfect  health,  with 
the  sudden  development  of  grave  symptoms,  complete  retention 
of  gases,  and  slight  meteorism. 

(2)  Ileus  in  consequence  of  torsion  (volvulus).  The  torsion  of 
the  intestine  around  its  mesenteric  axis  affects  the  sigmoid  flexure 
in  two-thirds  of  all  the  cases.  Volvulus  of  the  ascending  colon  and 
of  the  small  intestine  is  more  rare,  and  that  of  the  cecum  and 
transverse  colon  most  rare.  Volvulus  of  the  sigmoid  flexure  occurs 
oftenest  between  the  stges  of  forty  and  sixty.  Men  are  more 
likely  to  be  affected  than  women,  and  the  distortion  occurs  more 
frequently  in  connection  with  chronic  constipation  than  otherwise. 
The  course  is  less  violent  than  that  of  ileus  of  the  small  intestine. 
Local  meteorism  is  often  present. 


ETIOLOGY  743 

(3)  Ileus  in  consequence  of  invagination  or  intussusception. 
By  this  is  meant  the  invagination  <>l'  one  section  of  the  gut  into 

another  section,  SO  that  finally  three  tubes  are  pushed  one  into 
another.  The  intussusception  nearly  always  takes  place  in  a  down- 
ward direction  and  throughoul  a  rather  long  distance.  The  intus- 
susception of  the  small  into  the  large  intestine  is  most  frequent 
(invaginatio  ileocecalis) ;  then  follows  the  intussusception  of  small 
intestine  into  small  intestine  (invaginatio  enterica);  and  finally  the 
intussusception  of  large  intestine  into  large  intestine  (invaginatio 
colica).  The  appendix  vermiformis  may  occasionally  be  involved 
in  an  intussusception. 

About  one-half  of  all  the  cases  of  acute  intussusception  occur 
in  children  from  the  first  to  the  tenth  year;  the  more  chronic  variety 
is  found  most  often  in  patients  between  thirty  and  forty  years  of 
age.  The  male  sex  is  predisposed.  The  occurrence  of  the  intussus- 
ception is  explained  either  by  a  spasm  of  the  intestine  or  by  paralysis 
of  a  few  single  intestinal  coils.  The  sudden  onset  of  the  most 
agonizing  pain,  later  becoming  intermittent,  is  the  most  character- 
istic sign  of  intussusception.  Vomiting  occurs  very  soon,  but  is 
not  present  as  frequently  as  in  other  forms  of  ileus.  The  appear- 
ance of  bloody,  mucosanguineous  and  mucopurulent  evacuations 
and  the  expulsion  of  gangrenous  shreds  of  tissue,  accompanied  by 
marked  tenesmus,  is  typical.  Meteorism  is  seldom  a  prominent 
feature.  Of  great  diagnostic  importance  is  the  tumor  produced 
by  the  intussusception,  which  can  be  felt  in  many  cases  by  palpa- 
tion of  the  abdomen  simultaneously  with  rigidity  of  the  intestine 
during  the  paroxysm  of  pain.  The  tumor  may,  under  certain  cir- 
cumstances, prolapse  through  the  rectum,  and  most  frequently 
does  in  invaginatio  colica  and  ileocecalis. 

(4)  Ileus  subsequent  to  adhesions  formed  between  intestinal 
loops  themselves,  especially  in  cases  of  intestinal  ulcers. 

(5)  Ileus  by  process  of  contraction  in  the  mesentery. 

(6)  Ileus  in  consequence  of  compression  of  the  gut  by  malignant 
or  benign  neoplasms  of  the  other  abdominal  organs  (appendiceal 
abscess,  movable  spleen,  movable  kidneys,  diseases  of  the  pancreas). 

1 7 )  Arteriomesenteric  contraction  in  cases  of  extreme  acute 
dilatation  of  the  stomach  (see  page  486). 

II.  Internal  Ileus. — (8)  Ileus  from  strictures  of  the  intestine  in 
consequence  of  ulcerative  processes  (tuberculosis,  dysentery, 
syphilis),  formation  of  cicatrices,  malignant  tumors  (carcinoma), 
and  chronic  inflammatory  conditions  of  the  gut. 

(9)  Ileus  from  calculi:  (a)  By  gallstones,  more  frequent  in  the 
female  than  in  the  male;  usually  occurs  between  the  ages  of  forty 
and  sixty.  The  diagnosis  is  based  on  the  previous  history  and  the 
presence  of  changes  in  the  liver,  (b)  By  enteroliths.  These  are 
most  often  situated  in  the  ampulla  recti  or  in  the  recesses  made  by 
the  sacculation  of   the  colon.     The  diagnosis  of   this  rare  condi- 


744  OBSTRUCTION  OF  THE  INTESTINE 

tion  is  only  possible  when  the  hard  concretions  are  located  in 
the  rectum.  In  some  cases  the  Roentgen  ray  may  disclose  their 
presence.  Concretions  may  result  from  vegetable  sclerenchyma 
in  the  residue  of  undigested  fruit  or  vegetables. 

(10)  Ileus  in  consequence  of  foreign  bodies  which  have  gained 
access  into  the  bowel  by  way  of  either  the  mouth  or  the  anus. 
This  form  of  ileus  must  be  particularly  kept  in  mind  in  dealing 
with  the  insane.  Artificial  teeth,  needles,  pins,  nuts,  marbles, 
stones  and  beads  are  some  of  the  foreign  bodies  that  gain  entrance 
to  the  intestine. 

(11)  Ileus  from  fecal  tumors,  a  rare  occurrence  which  may 
supervene  in  cases  of  chronic  constipation.  A  fecal  mass  may 
attain  an  enormous  size. 

(12)  Ileus  from  the  accumulation  of  large  numbers  of  ascarides 
— quite  rare. 

III.  Paralytic  and  Spastic  Ileus. — Paralytic  ileus  occurs  in 
cases  of  marked  paralysis  of  the  intestine,  in  severe  traumatic 
injuries,  in  long-continued  grave  constipation,  after  abdominal 
operations,  and  in  peritonitis  and  appendicitis.  It  is  explained 
either  by  injury  to  the  nerve  fibers  supplying  the  muscle  fibers 
of  the  gut,  or  by  .reflex  processes.  A  particularly  striking  example 
is  afforded  by  the  ileus  which  occurs  when  a  testicle  is  retained 
and  becomes  inflamed  in  the  abdominal  cavity. 

Spastic  contraction  of  an  intestinal  loop,  which  may  become  no 
larger  than  a  finger,  supervenes  without  any  known  cause  reflexly 
from  derangement  of  the  vegetative  nervous  system  (see  page 
387),  in  connection  with  the  other  forms  of  ileus  and  in  gastric 
crises. 

Angulations  are  anatomic  throughout  the  colon;  and  all  will 
recognize  the  terms  hepatic  flexure,  splenic  flexure,  sigmoid  flexure, 
and  rectosigmoid  flexure.  In  normal  conditions  these  flexures 
retard  to  a  slight  degree  the  fecal  current,  and  when  through  dis- 
placement or  any  other  cause  the  bend  is  exaggerated  the  obstruc- 
tion is  proportionately  increased  (Figs.  106  and  107).  Thus  in 
gastroenteroptosis  (see  Chapter  XXX)  the  transverse  colon  is 
carried  downward  in  the  abdominal  cavity,  and  unless  the  ligaments 
give  way  the  normal  hepatic  and  splenic  flexures  become  more  and 
more  acute  and.  obstructive  as  the  colon  descends.  This  accounts 
for  the  distention  and  tenderness  over  the  cecum  in  such  cases. 
In  many  instances  of  this  kind  the  right  kidney  and  the  hepatic 
flexure  descend  along  with  the  transverse  colon,  and  then  only 
the  splenic  flexure  is  accentuated. 

If  ileus  occurs  in  obese  individuals  from  no  assignable  cause, 
acute  pancreatitis  should  be  thought  of.  Frequently  there  is  also 
pain  in  the  pancreatic  region,  which  may  either  be  spontaneous  or 
elicited  on  pressure;  moderate  fever;  and  transient  excretion  of 
sugar. 


SYMPTOMS 


745 


As  ;m  aid  to  diagnosis  in  acute  intestinal  obstruction  the  stomach 
tube  should  be  passed  from  hour  to  hour  and  the  contents  carefully 
examined.  Ii'  those  arc  dark  brown,  with  a  fecal  odor,  acute  intes- 
tinal obstruction  may  be  diagnosed.  An  early  and  constant  mani- 
festation of  intestinal  obstruction  isacute  dilatation  of  the  stomach 
(see  page  486).  Adhesions  can  usually  be  demonstrated  by  means 
of  the  bismuth  mixture  and  the  Roentgen  ray.  Both  the  fluoro- 
scopic  examination  and  a  number  of  roentgenograms  may  be 
necessary. 


Fig.  106. — Acute  flexure  of  the  sigmoid  bound  by  adhesion  to  the  rectum.     (Tuttle.) 


Symptoms. — One  of  the  first  symptoms  of  ileus  is  abdominal 
pain,  which  varies  in  intensity  and  is  sometimes  of  intolerable 
violence,  especially  in  ileus  of  the  small  intestine;  in  contradistinc- 
tion to  the  pains  of  stenosis,  those  of  ileus  are  more  continuous  in 
character.     The  pain  from  obstruction  of  the  small  intestine  is 


746 


OBSTRUCTION  OF  THE  INTESTINE 


always  located  above  the  umbilicus,  while  that  of  the  large  intes- 
tine is  always  at  or  below  the  umbilicus.  The  pains  are  usually 
associated  with  vomiting,  which  persists  from  the  beginning  until 
the  end  of  the  disease.  At  first  the  contents  of  the  stomach  are 
ejected,  then  the  vomitus  becomes  feculent,  and  finally  absolute 
fecal   vomiting   supervenes.     This   is    accompanied   by   complete 


Fig.  107. — Acute  flexure  of  the  sigmoid  bound  by  adhesion  with  chronic  appendicitis. 

(Tuttle.) 


obstipation  and  the  absence  of  flatus  through  the  rectum.  Very 
soon  after  the  development  of  the  ileus  the  abdomen  becomes 
greatly  distended  by  meteorism;  this  is  most  marked  in  cases  of 
ileus  low  down  in  the  large  intestine.  The  whole  length  of  the 
intestine  is  usually  distended  so  that  the  meteorism  affects  the 
whole  of  the  abdominal  cavity.  More  rarely  there  is  local  mete- 
orism, which  when  situated  in  the  intestinal  loops  affected  by  the 


TREATMENT  747 

occlusion  may  become  diagnostically  important.  Differing  from 
stenosis,  peristaltic  movements  arc  entirely  absent  in  ileus,  or  only 
traces  may  be  discovered  in  a  lew  single  coils  of  the  intestine. 
The  general  condition  of  the  patient  becomes  exceedingly  grave 

in  a  remarkably  short  time  from  the  commencement  of  the  disease; 
this  is  due  to  the  shock  caused  by  the  ileus,  and  is  most  strongly 
marked  in  cases  involving  the  small  intestine.  The  general  condi- 
tion is  aggravated  by  the  total  loss  of  appetite,  by  the  impossibility 
of  ingesting  food,  by  extreme  thirst,  and  by  intestinal  toxemia. 
To  this  grave  general  collapse  there  is  soon  added  weakness  of  the 
heart.  The  quantity  of  urine  excreted  is  very  small.  In  the  first 
days  of  the  occlusion  of  the  small  intestine  large  quantities  of 
indican  are  found  in  the  urine,  and  this  point  is  of  diagnostic-  value 
in  excluding  ileus  of  the  large  intestine.  The  indicanuria  is  diag- 
nostic-ally useless  in  the  later  stages  of  the  disease.  Hemorrhages 
from  the  bowel  take  place  occasionally;  they  are  especially  apt 
to  occur  in  cases  of  intussusception,  strangulation,  gallstone  ileus, 
and  volvulus.  In  volvulus  particularly,  necrotic  perforation  and 
peritonitis  are  among  the  imminent  dangers.  ^Yhen  the  symptoms 
persist  without  any  change,  the  disease  becomes  continuously 
worse  and  finally  causes  death,  the  patient  retaining  consciousness, 
in  occasional  instances,  until  the  last. 

The  toxemia  which  develops  is  due  to  a  primary  proteose  (Whip- 
ple) which  may  be  precipitated  by  alcohol  or  ammonium  sulphate 
solution.  This  poison  is  easily  isolated  from  closed  loops  of  the 
intestine  and  has  been  found  to  be  very  toxic. 

Clinicians  now  believe  that  death  caused  by  intestinal  obstruc- 
tion is  due  to  the  absorption  of  toxins  originating  in  the  epithelium 
of  the  duodenum  or  other  parts  of  the  digestive  tract. 

Treatment. — In  a  case  of  ileus  the  question,  after  establishing  the 
diagnosis,  is,  whether  a  conservative  internal  treatment  is  properly 
indicated,  or  whether  the  case  should  be  immediately  referred  to 
the  surgeon.  The  possibility  of  a  recovery  by  means  of  internal 
treatment  is  least  favorable  or  even  nil  in  cases  of  strangulation 
and  internal  hernia,  intussusceptions,  internal  strictures,  retraction 
of  the  mesentery,  adhesions  of  intestinal  loops,  and  ileu^  caused 
by  compression.  All  these  cases  belong  per  se  to  surgery,  but  the 
results  from  operative  measures  are  best  in  external  hernia.  In 
cases  of  incarceration  and  of  strangulation  a  cure  by  internal  treat- 
ment is  practically  impossible;  operation  should  be  preferred. 
Intussusception  treated  surgically  is  less  often  fatal  than  after 
internal  treatment.  The  treatment  of  intestinal  obstruction  can 
only  be  surgical;  the  results,  however,  are  not  satisfactory  because 
of  the  character  of  the  disease  (tuberculosis,  carcinoma).  Opera- 
tive intervention  offers  a  poor  prognosis  in  cases  of  retraction  of 
the  mesentery,  and  in  cases  of  adhesions  between  intestinal  loops 
subsequent  to  ulceration  (tuberculosis). 


748  OBSTRUCTION  OF  THE  INTESTINE 

The  surgical  results  are  often  unsatisfactory  in  all  forms  of 
ileus  because  the  patients  are  transferred  to  the  surgeon  far  too 
late.  The  possibility  of  benefit  bears  a  close  relation  to  the  time 
of  the  operation,  which  should  take  place  within  the  first  forty- 
eight  hours.  A  patient  with  ileus  rapidly  loses  his  power  of  resist- 
ance to  shock,  so  that  operations  which  are  trifling  in  themselves 
often  result  fatally.  Intestinal  toxemia  and  septic  conditions  also 
play  an  important  part.  Furthermore,  the  results  are  frequently 
bad  because  during  the  operation  complications,  are  discovered 
which  either  greatly  prolong  the  time  of  the  operation  or  render  it 
impossible  to  remove  the  obstruction.  The  vomiting  deprives  the 
organism  of  nutrient  materials  and  water.  Normal  saline  injections 
supply  both  waiter  and  chlorin  to  the  body  and  thus  prevent  desic- 
cation of  the  tissues.  Saline  transfusion  (hypodermoclysis)  should 
always  be  practiced  in  intestinal  obstruction  pending  the  decision 
as  to  operative  measures. 

Ileus  due  to  stones  or  foreign  bodies  does  not  offer  very  good 
operative  possibilities,  and  may  at  first  be  treated  by  medical 
means  because  it  is  occasionally  possible  to  remove  the  obstacle 
in  this  manner.  When  this  is  impossible,  it  is  absolutely  necessary 
to  operate. 

Volvulus  of  the  sigmoid  flexure  may  reduce  itself  spontaneously; 
this  generally  takes  place  slowly,  and  it  is  proper  to  wait  two  or 
three  days  for  the  spontaneous  reduction ;  no  internal  medication  is 
known  that  will  directly  improve  the  condition. 

Pushing  massage  of  the  abdomen,  when  carefully  done,  is  of 
great  help  (Fig.  108).  The  patient  assumes  the  knee-chest  posi- 
tion, the  physician  standing  at  his  left  side.  The  palms  of  the 
physician's  hands  are  on  the  anterior  surface  of  the  abdomen  under- 
neath. The  right  hand  lies  between  the  umbilicus  and  symphysis 
transversely  across  the  abdomen;  the  left  hand  likewise  lies  trans- 
versely but  between  the  umbilicus  and  the  ensiform  process.  The 
physician  exerts  alternate  pressure  above  and  below,  passing  both 
hands  in  the  longitudinal  direction  of  the  abdomen.  At  each 
push  the  hands  simultaneously  approach  the  umbilicus  and  move 
away  from  it. 

Fecal  tumors,  ascarides  ileus,  spastic  and  paralytic  ileus  must  be 
treated  internally. 

The  field  for  the  activity  of  the  surgeon  in  the  treatment  of  ileus 
is  thus  theoretically  very  extensive.  But  unfortunately  surgical 
intervention  in  cases  of  ileus  is,  as  stated  above,  surrounded  by 
so  many  dangers  and  complications  that  in  practice,  considering 
everything,  medical  and  surgical  treatment  may  be  regarded  as 
about  on  a  par  so  far  as  results  are  concerned.  Of  course  the 
principle  should  be  held  firmly  that,  when  diagnosis  is  established, 
operation  should  follow  as  soon  as  possible,  before  the  condition  of 
the  patient  becomes  grave.     In  those  cases  also  in  which  internal 


TREATMEh  T 


749 


treatment  is  permissible  t'<>r  ;i  time,  it  is  better  not  to  persist  in 
such  measures  too  long.  The  object  of  any  kind  of  operation  is, 
first  nf  all,  the  removal  of  the  obstruction.  This  may  consist  in 
the  separating  of  adhesions,  the  release  of  stones  within  the  intes- 
tine, the  resection  of  large  or  small  portions  of  the  intestine,  or  the 
removal  of  compressing  pathologic  conditions.  It  may  happen 
that  it  is  impossible  to  perform  a  radical  operation.  Then  there 
is  the  possibility  of  either  entero-anastomosis  with  exclusion  of 
the  diseased  portion  of  the  gut,  or  enterostomy  with  establishment 
of  an  artificial  anus.  These  palliative  operations  are  often  very 
serviceable,  and  frequently  when  the  general  condition  is  improved 
the  radical  operation  may  be  attempted  later. 


l'i(..  108. — Pushing  massage  of  the  abdomen  for  volvulus.   (Zabludowski-Eiger.) 

In  the  internal  treatment  of  ileus  the  primary  indication  is  to 
counteract  the  rapid  failure  of  the  patient's  strength;  and  to  this 
end  dietetic  measures  are,  of  course,  of  greatest  importance  if  at 
all  practicable.  It  must  be  our  constant  endeavor  to  introduce 
into  the  body  the  greatest  utilizable  number  of  calories;  and  for 
guidance  we  should  know  whether  the  ileus  affects  the  large  or  the 
small  intestine.  In  cases  of  ileus  of  the  small  intestine,  nutrition 
by  mouth  is  often  impossible  because  of  the  absolute  loss  of  appetite 
and  the  continuous  vomiting.     In  such  cases  it  is  not  at  all  desirable 


750  OBSTRUCTION  OF  THE  INTESTINE 

to  administer  much  by  the  mouth,  since,  even  if  it  were  retained, 
it  would  add  a  new  burden  to  the  intestine.  Rectal  alimentation 
should  preferably  be  freely  employed.  In  cases  in  which  nutritious 
enemata  are  retained  badly,  subcutaneous  nutrition  may  be  em- 
ployed in  the  form  of  transfusion  of  solutions  of  protein,  sugar 
or  fat,  or  percutaneous  nutrition  by  means  of  inunctions  of  fat 
into  the  skin.  Generally  speaking,  very  little  success  will  be 
attained  by  this  method  of  feeding,  but  it  is  possible  that  in  some 
few  cases  subcutaneous  nutrition  may  contribute  slightly  to  the 
sustenance  of  the  bodily  strength  and  may  therefore  be  justified 
as  a  last  resort.  Then,  too,  the  patient's  spirits  are  kept  up  by 
the  idea  that  something  is  being  done  for  him.  In  cases  of  this 
kind,  with  low  nutritional  conditions,  physiologic  salt  solution 
(0.9  per  cent.)  should  be  administered  either  subcutaneously  or  by 
proctoclysis.  By  this  means  the  paucity  of  water  in  the  organism 
is  counteracted,  and  the  water  introduced  assists  in  eliminating 
toxic  substances  from  the  body  by  directly  stimulating  diuresis. 
When  the  blood-pressure  is  rapidly  decreasing  during  the  first 
acute  stage,  the  intestine  not  having  yet  become  paralyzed,  some 
surgeons  recommend  intravenous  transfusion  of  normal  saline 
solution  with  the  addition  of  a  few  drops  of  epinephrin  solution. 

Conditions  are  quite  different  in  ileus  of  the  large  intestine. 
Here  it  is  possible  for  the  upper  portions  of  the  gut  to  partly  digest 
and  absorb  some  of  the  proper  food.  Food  should  therefore  be 
given  in  as  large  quantities  as  possible,  but  the  diet  should  consist 
of  liquids  only,  or  liquids  with  the  occasional  addition  of  semi- 
solids. The  following  are  suggested:  milk,  cream,  beef  tea,  beef 
jelly,  meat  juice,  beef  tea  preparations  containing  protein,  liquid 
egg  dishes,  gruels  and  soups  with  flour,  legumes,  and  addition  of 
butter  and  eggs.  All  these  foods  should  be  given  frequently  and 
in  small  portions.  When  there  is  a  tendency  to  vomiting,  the 
milk  should  be  given  cold,  but  this  is  inadmissible  when  there 
is  severe  colicky  pain.  The  administration  of  small  quantities  of 
alcohol,  pure  or  as  an  addition  to  suitable  foods,  has  a  favorable 
action  on  the  heart.  Abundant  quantities  of  liquids  by  the  mouth, 
subcutaneously,  and  per  rectum,  are  indicated.  Also  feeding  by 
rectum  should  be  instituted  if  practicable  (see  page  243). 

The  care  of  the  strength  of  the  patient  being  provided  for  by 
these  methods,  the  question  arises:  What  are  the  important  reme- 
dies at  our  disposal  for  directly  attacking  the  ileus?  Lavage  of 
the  stomach  may  act  favorably,  particularly  in  ileus  of  the  small 
intestine,  and  possibly  be  the  means  of  saving  life.  The  lavage 
should  be  done  quite  early  in  the  attack,  especially  when  feculent 
vomiting  is  a  feature  of  the  case;  if  the  decomposing  materials 
above  the  obstruction  can  be  removed,  as  is  sometimes  possible, 
by  means  of  gastric  lavage,  the  stagnation  is  relieved  and  the 
excessive  peristaltic  movement  diminished.     Another  effect  is  the 


TREATMENT  751 

reduction  of  pressure  above  the  closure — which  may  mean  the 
removal  of  an  obstacle  to  the  spontaneous  overcoming  of  the 
obstruction.  Lavage  of  the  stomach  should,  as  a  rule,  be  instituted 
during  the  first  forty-eight  hours,  but  when  the  general  condition 

is  satisfactory  it  may  be  postponed  somewhat  longer.  When  the 
heart  is  alarmingly  weak  and  the  patient  very  low,  lavage  may 
sometimes  turn  the  scale  in  favor  of  recovery;  at  this  stage,  how- 
ever, it  severely  taxes  the  remaining  powers  of  resistance,  and 
under  some  circumstances  hastens  the  fatal  issue.  The  washing- 
out  of  the  stomach  must  be  done  several  times  daily  (two  to  five 
times),  or  at  least  twice  a  day.  Each  single  lavage  must  be  con- 
tinued until  the  water  returns  clear,  and  the  stomach  should  be  left 
quite  empty.  The  next  washing  is  always  made  at  a  time  when 
the  stomach  again  becomes  distended,  indicating  a  regurgitation 
of  new  material  into  it. 

If  necessary,  morphin,  0.01  Gm.  (\  grain),  should  be  given 
subcutaneously  prior  to  the  lavage.  In  the  presence  of  great 
weakness,  camphor  or  caffein,  0.1  Gm.  (1^  grains)  subcutaneously, 
is  indicated. 

As  stated  above,  the  question  of  the  utility  of  lavage  arises 
particularly  in  cases  of  ileus  of  the  small  intestine.  Its  great 
efficiency  is  well  known  in  arteriomesenteric  contraction  in  conse- 
quence of  acute  gastric  dilatation  (see  page  486).  It  usually  fails 
in  cases  of  volvulus,  intussusception  of  the  large  intestine,  internal 
strictures,  stones,  fecal  tumors,  and  paralytic  and  spastic  ileus. 

Sometimes  rectal  injections — which  can  only  be  considered  in 
ileus  of  the  large  intestine — do  very  well.  The  quantity  of  wTater 
introduced  may  act  in  an  altogether  mechanical  way  on  the  ob- 
struction by  virtue  of  the  pressure  it  exerts  on  intussusceptions; 
it  may  loosen  foreign  bodies  and  stones;  it  may  reduce  a  volvulus, 
soften  fecal  tumors,  and  in  paralysis  of  the  intestine  it  may  stimulate 
peristalsis.  Water  enemata  with  soap  and  oil  are  the  best  for  this 
purpose. 

When  it  is  intended  to  employ  strong  pressure  upon  the  point 
of  closure,  it  is  best  to  allow  two  or  three  liters  (quarts)  of  normal 
saline  solution  to  flow  in  by  means  of  a  long  rectal  tube,  strongly 
compressing  the  anus  manually,  the  patient  meanwhile  maintaining 
the  knee-chest  position.  When  larger  volumes  of  water  are  used, 
care  should  be  taken  to  see  that  all  of  the  water  returns  before  a 
renewal  of  the  injection  is  attempted.  Otherwise  it  is  easily  possible 
for  the  large  intestine  to  become  overdistended,  with  resulting 
perforation. 

Xothnagel  has  recommended  the  employment  of  ice-water,  and 
the  use  of  the  siphon  (Fig.  34)  by  which  ice-cold  water  containing 
carbon  dioxid  is  allowed  to  pass  in  through  a  rectal  tube  under 
high  pressure. 

Good  effects  have  been  reported  from  the  employment  of  ether: 


752  OBSTRUCTION  OF  THE  INTESTINE 

70  Cc.  (5ij|)  of  ether  with  300  Cc.  (§x)  of  water  is  made  to  flow 
into  the  rectum  through  a  soft-rubber  rectal  tube.  These  injec- 
tions are  to  be  repeated  several  times  daily,  until  flatus  and  feces 
are  discharged. 

The  patient  should  always  be  given  the  benefit  of  extensive 
irrigation  of  the  bowel  before  surgical  intervention  is  resorted  to. 
Not  infrequently,  in  cases  that  look  hopeless,  evacuation  is  accom- 
plished in  this  way.  For  this  purpose  I  have  found  the  supernatant 
oil  apparatus  (Fig.  109)  invaluable.  This  is  a  glass  bulb  (6)  with 
two  lateral  openings,  to  one  of  which  a  short  soft-rubber  rectal 
tube  (a)  is  attached,  and  to  the  other  an  ordinary  rubber-bulb 
syringe  (c).  The  apparatus  is  easily  improvised;  any  glass  bulb 
with  two  openings  will  answer.  The  bulb  is  filled  with  olive  oil  (it 
should  hold  about  250  Cc,  or  half  a  pint),  and  the  free  end  of  the 
syringe  is  inserted  into  a  basin  (d)  containing  two  liters  (quarts) 
of  water.  On  pressing  the  bulb  (c),  the  water  forces  the  oil  into  the 
intestine.  On  account  of  the  lighter  specific  gravity  of  the  oil, 
it  precedes  the  water  through  the  coils  of  the  colon.  This  method 
is  more  likely  to  produce  an  evacuation  than  the  use  of  either  water 
or  oil  alone.  I  rarely  call  for  the  aid  of  the  surgeon  before  I  have 
used  this  apparatus. 

a 


Fig.  109. — Supernatant  oil  apparatus,    a,  rectal  tube;  b,  glass  container  for  oil; 
c,  rubber  bulb  syringe;  d,  basin  for  water. 

The  distention  of  the  intestine  with  air  serves  the  same  purpose. 
The  liberation  of  intussusceptions  has  often  been  observed  after 
this  procedure;  and  foreign  bodies  and  stones  may  likewise  be 
loosened,  and  angulations  straightened  out.  Insufflations  with  air 
are  contra-indicated  when  an  ulcer  is  suspected,  ard  in  cases  of 
necrosis,  hemorrhage  or  peritonitis. 

The  Noble1  enema  is  highly  recommended  when  there  is  difficulty 
in  obtaining  a  movement  of  the  bowels : 

Gm.  or  Cc. 

1$ — Magnesii  sulphatis 6010  o  i.l 

Glycerini 60 10  oij 

Olei  terebinthinse 15 1 0  §ss 

Aquae       .- q.  s.  ad     240 10  gviij 

Misce. 

Sig. — Use  as  an  enema  and  retain  as  long  as  possible. 

When  fecal  tumors  are  located  near  the  anus,  the  rectum  may 
have  to  be  cleared  out  manually,  and  bile  enemata  are  particularly 
efficacious  (see  page  226). 

1  This  formula  was  first  published  by  C.  P.  Noble,  of  Philadelphia  and  recom- 
mended by  him  for  producing  the  most  positive  results  in  paretic  bowels. 


TREATMENT  7.".:; 

Occasionally  recovery  may  result  from  puncture  of  the  intestine 
as  recommended  by  Curschmann.  This  procedure  is  not  recom- 
mended unless  surgery  is  absolutely  contra-indicated.  In  such 
eases,  after  puncture,  there  is  a  diminution  in  the  tension  iii  the 
intestinal  Loops,  in  consequence  of  which  the  incarcerated  portions 
of  the  gut  can  more  readily  return  to  the  normal  position.  The 
puncture  is  performed  in  the  following  manner: 

A  long  cannula  (provided  with  a  stopcock)  of  the  size  of  a  Pravaz 
syringe  needle  is  carefully  sterilized  and,  the  stopcock  being  closed, 
is  inserted  into  an  intestinal  coil.  The  cannula  is  then  connected 
with  a  rubber  tube,  and  this  is  conducted  into  a  bottle  filled  with  a 
watery  solution  of  salicylic  acid,  which  is  inverted  in  a  basin  con- 
taining a  similar  solution.  When  the  stopcock  of  the  cannula  is 
opened  the  intestinal  gases  pass  into  the  bottle,  at  first  in  one  con- 
tinuous stream  and  later  on  more  slowly.  Meanwhile  the  cannula 
must  not  be  held  tightly;  its  guidance  is  to  be  left  to  the  intestine. 
Punctures  may  be  made  at  various  points  and  should  be  frequently 
repeated.  Puncture  of  the  intestine  may  be  undertaken  in  cases  of 
strangulation  and  of  volvulus,  but  surgery  is  better.  It  is  strictly 
contra-indicated  in  intestinal  paresis,  in  intussusception,  in  peritonitis, 
and  when  gangrene  is  suspected. 

A  few  physicians  have  recommended  massage  of  the  abdomen, 
but  as  a  rule  this  can  only  be  considered  in  cases  of  ileus  due  to 
fecal  tumors.  At  any  rate  it  is  never  to  be  employed  without  the 
exercise  of  the  utmost  caution,  because  of  the  danger  of  peritonitis 
and  of  perforation. 

Warm  applications  and  Priessnitz  bandages  to  the  abdomen  are 
symptomatically  pleasant  (see  page  250). 

Medication. — Purgatives  (see  Chapter  XIV)  are  permissible  in 
ileus  due  to  fecal  tumors,  for  softening  the  hard  fecal  masses  and 
for  assisting  their  passage  by  stimulation  of  the  peristaltic  move- 
ments. In  ileus  paralyticus  castor  oil  may  be  given,  and  its  action 
assisted  by  enemata.  In  all  other  cases  of  ileus,  purgatives  act 
injuriously  by  increasing  the  peristaltic  movements  which  are 
already  excessive,  thus  rendering  the  removal  of  the  obstruction 
more  difficult.  On  the  other  hand,  some  anodynes  have  a  beneficial 
action  (see  page  274).  First  of  all,  opium.  This  drug  relieves  the 
pains,  acts  as  a  general  sedative,  diminishes  shock,  and  induces 
sleep.  It  also  lessens  the  vomiting  and  quiets  the  convulsive  con- 
tractions of  the  intestine.  Consequently  opium  favors  the  possi- 
bility of  a  spontaneous  liberation  of  the  obstruction.  It  also  acts 
as  a  prophylactic  against  local  peritonitis,  which  is  likely  to  occur 
when  the  ileus  has  existed  for  some  time;  by  its  antispasmodic  action 
the  opium  prevents  traction  upon  the  inflamed  peritoneum.  Opium 
is,  however,  indicated  only  in  the  first  stage  of  ileus,  and  not  then 
when  the  heart  is  weak  or  the  general  depression  extreme.  Xor 
should  one  forget  that  the  sense  of  well-being  experienced  by  the 
48 


754  OBSTRUCTION  OF  THE  INTESTINE 

patient  as  a  result  of  the  administration  of  opium  may  conceal  the 
true  state  of  affairs,  making  the  case  appear  to  be  much  more  favor- 
able than  it  actually  is.  It  is  well,  therefore,  to  limit  the  use  of 
this  drug,  that  an  unbiased  view  of  the  case  may  be  obtained. 

In  the  past  ten  years  rather  pleasing  results  have  followed  the 
administration  of  atropin  in  ileus.  It  is  well  known  that  atropin 
in  small  doses  relieves  vagotonia  and  has  a  stimulating  effect  upon 
the  muscular  elements  of  the  intestine,  and  therefore  serves  to 
liberate  spastic  ileus  and  spastic  conditions  of  the  intestine  due  to 
mechanical  obstruction.  It  is  necessary  from  the  very  beginning, 
however,  in  such  cases,  to  employ  large  doses — doses  which  exceed 
the  official  maximum.  If  the  patient  has  taken  opium  previously, 
0.005  Gm.  (tV  grain)  of  atropin  sulphate  should  be  given  without 
any  delay,  and  this  dose  should  be  repeated  if  no  improvement 
shows  itself  after  twelve  hours.  The  opium  antagonizes  part  of  the 
atropin,  so  these  large  doses  do  not  induce  any  serious  symptoms 
of  poisoning.  If  no  opium  has  been  given  previously,  the  initial 
hypodermic  injection  of  atropin  should  be  0.002  Gm.  (■%-$  grain), 
and  after  twelve  hours  another  dose,  of  0.005  Gm.  (ty  grain).  If, 
twenty-four  hours  subsequent  to  the  giving  of  atropin,  no  flatus 
has  been  expelled,  it  will  hardly  be  advisable  to  push  this  medica- 
tion further.  Possible  symptoms  of  toxemia,  delirium,  hallucina- 
tions or  convulsions  are  counteracted  by  morphin  (see  page  275). 

Occasionally  physostigmin  also  may  be  given,  with  great  caution, 
thus:  0.001  to  0.002  Gm.  (-gV  to  ¥V  grain)  physostigmin  salicylate, 
or  0.001  or  0.01  Gm.  (^  to  |  grain)  physostigmin  sulphate  (see 
page  283). 

Effects  similar  to  those  of  atropin  and  physostigmin  may 
apparently  be  produced  by  pituitary  extract  or  by  the  peristaltic 
hormone  (see  page  667)  which  may  now  be  considered  a  valuable 
addition  to  the  internal  remedies  at  our  "disposal  for  the  treatment 
of  this  form  of  ileus.  It  induces  a  peristaltic  motion  approximating 
the  physiologic  more  closely  than  that  induced  by  physostigmin. 


CHAPTER  XLVII. 
STRICTURES  OF  THE  INTESTINE. 

Stricture  of  the  intestine  consists  of  abnormal  narrowing  of 
the  bowel,  from  either  cicatricial  contraction  or  the  deposit  of  adven- 
titious tissue. 

Strictures  or  stenoses  of  the  duodenum  or  the  jejunum  are  called 
"high,"  while  those  that  occur  at  any  point  from  the  beginning  of 
the  ileum  onward  are  described  as  "low"  or  "deep"  strictures. 

STRICTURES  OF  THE  SMALL  INTESTINE. 

Symptoms. — Strictures  situated  just  below  the  pylorus  and  above 
the  papilla  of  Vater  (suprapapillary  stenoses)  generally  induce  the 
same  symptoms  as  stenosis  of  the  pylorus.  The  most  prominent 
symptoms  are  referable  to  the  stomach,  particularly  vomiting  of  the 
stomach  contents.  In  such  cases  the  correct  diagnosis  is  usually 
difficult  to  arrive  at,  and  stenosis  of  the  pylorus  is  assumed  to  be 
present  (page  490).  A  frequent  cause  of  this  form  of  stricture  is 
wedged-in  gallstones,  which  are  too  large  to  find  their  way  into  the 
gut  but  are  forced  by  the  bile  and  the  natural  expulsive  effort  of 
the  bile  duct  into  a  "corner,"  so  to  speak.  Furthermore,  adhesions 
and  strictures  subsequent  to  duodenal  ulcers  and  carcinoma  may 
possibly  be  present. 

Stricture  situated  below  the  papilla  of  Vater  (infrapapillary 
stenoses)  but  in  the  duodenum  also  induce  gastric  symptoms,  such 
as  distention,  pressure,  pain,  eructation,  nausea  and  vomiting. 
But  in  these  cases  the  vomited  matter  does  not  consist  of  pure  gastric 
contents,  for  the  regurgitating  chyme  is  mixed  with  the  digestive 
secretions  of  the  intestine,  the  pancreatic  juice  and  the  bile,  and  is 
discolored  by  the  latter.  The  finding  of  such  intestinal  secretions, 
in  the  stomach  contents  may  be  of  high  diagnostic  value. 

The  vomiting,  as  in  stenosis  of  the  pylorus,  may  continue  after 
the  ingestion  of  any  food,  because  there  is  a  continuous  pressure 
backward  in  consequence  of  the  stricture  being  situated  so  short 
a  distance  below  the  stomach.  Accentuated  peristaltic  move- 
meats  are  not  usually  found  in  these  strictures,  because  the  liquid 
chyme  is  able  to  pass  through  the  stricture  or  escape  back  toward 
the  stomach.  This  also  accounts  for  the  absence  of  colicky  pains. 
The  bowels  are  usually  moderately  constipated,  and  the  feces  may 
be  light  in  color  in  consequence  of  the  absence  of  biliary  coloring 


756  STRICTURES  OF  THE  INTESTINE 

matter.  The  urine  may  be  rich  in  indican.  The  appetite  quickly 
decreases  as  the  stagnation  persists;  the  body  weight  fails,  and  the 
percentage  of  water  is  greatly  diminished.  The  stomach  itself 
may  be  either  normal  in  size  or  dilated;  during  the  early  stages  of 
the  disease  it  may  perform  its  secretory  functions  quite  normally. 

When  the  stenosis  has  existed  for  some  time,  sarcinse  and  long 
bacilli  are  usually  present.  When  palpation  reveals  a  tumor  in  the 
duodenal  region,  this  is  very  likely  a  carcinoma.  When  palpation 
is  negative,  the  previous  history  is  of  importance;  if  gallstone  colics 
have  occurred,  attention  should  be  given  to  the  possibility  of  an 
occlusion  by  gallstones,  or  of  adhesions — often  found  in  females.  In 
men  it  may  possibly  be  a  duodenal  ulcer  which  is  causing  the  stricture. 
The  diagnosis  of  probable  carcinoma  is  apt  to  be  correct  in  advanced 
life.  Other  affections  to  be  kept  in  mind  are:  lymphoraata,  sar- 
comata, compression  by  metastatic  tumors,  diseases  of  the  pancreas 
(cysts,  tumors,  adipose  tissue,  necrosis),  and  retroperitoneal  tumors. 

Stricture  of  the  jejunum  induces  gastric  symptoms.  Vomiting  is 
particularly  frequent,  but  does  not  take  place  as  often  as  it  does  in 
stricture  of  the  duodenum,  for  the  reason  that  there  is  more  space 
above  the  stenosis  for  the  collection  of  the  chyme.  The  vomiting, 
when  it  does  occur,  is  more  copious  than  in  duodenal  stricture. 
When  the  jejunal  stricture  is  situated  far  down,  the  vomited  matter 
gradually  assumes  fecal  characteristics  and  contains  bile. 

Stricture  of  the  Ileum. — The  intestinal  symptoms  predominate 
in  this  condition.  The  vomitus  becomes  fecal.  Peristaltic  move- 
ments are  both  visible  and  palpable,  and  colicky  pains  may  develop, 
particularly  in  cases  of  carcinoma.  The  intestinal  symptoms 
become  more  pronounced  in  proportion  to  the  relative  proximity  of 
the  stenosis  to  the  cecum.  As  a  rule,  however,  marked  symptoms 
appear  rather  late — only  during  the  more  advanced  stages  of  the 
stricture — and  are  preceded  by  vague  disturbances  of  bowel  func- 
tion, such  as  constipation  or  diarrhea  or  alternation  of  both.  Occa- 
sionally multiple  strictures  occur  simultaneously. 

The  causes  of  jejunal  and  iliac  strictures  are  adhesions,  kinks  and 
angulations  caused  by  gastroenteroptosis  (see  Chapter  XXX)  or 
inflammation  of  the  female  genital  apparatus  or  of  the  appendix, 
and  hernias.  Cicatrized  tuberculous  ulcers  are  rarely  the  origin 
of  strictures.  Syphilitic  strictures  are  very  rare.  Carcinomata 
occur  in  elderly  people  and  in  people  of  still  more  advanced  years. 
Stricture  of  the  small  intestine  can  often  be  made  out  by  means  of 
the  Roentgen  ray.  The  bismuth  shadow  shows  a  persistent  stag- 
nation for  many  hours.  Loops  of  the  intestine  may  appear  dilated 
either  as  abnormally  long,  band-like  shadows,  as  broad  as  the  colon, 
or  as  ampulla-like  hollow  spaces  as  large  as  an  orange,  or  even  as 
large  as  a  melon,  filled  with  fluid  or  gas.  Either  of  these  conditions 
is  suggestive  of  obstruction  in  the  intestine  (see  page  148). 


STh'ICTCh'l'JS  OF  THE  LARGE  INTESTINE  757 

STRICTURES  OF  THE  LARGE  INTESTINE. 

Symptoms. — In  this  class  of  cases  the  symptoms  generally  develop 
slowly.  The  first  sign  is  constipation,  which  may  persist  for  months 
or  even  years.  Constipation  should  arouse  suspicion  when  it  is 
found  in  people  of  mature  age  and  when  it  resists  treatment  with 
mild  purgatives  so  that  finally  the  strongest  drastic  medicaments 
are  resorted  to.  To  constipation  are  gradually  added  colicky  pains, 
to  which  slight  attention  is  at  first  given,  but  which  are  of  great 
weight  in  the  diagnosis.  Should  vomiting  begin,  the  suspicion  of 
stricture  grows.  Chronic  distention  with  gases  is  a  very  ominous 
objective  sign.  The  meteorism  is  least  marked  in  strictures  of  the 
rectum,  and  more  so  in  those  located  at  higher  levels  of  the  large 
intestine.  Increasing  meteorism  is  a  sign  of  the  presence  or  com- 
mencement of  paralysis  of  the  gut.  Of  more  importance  than 
meteorism  is  the  discovery  of  visible  peristaltic  movements  in 
connection  with  constipation  and  colicky  pains. 

The  typical  course  of  these  spastic  peristaltic  motions  is  from 
an  imperceptible  start,  accompanied  by  marked  pains,  to  a  rigid 
and  forcible  contraction  of  the  particular  section  of  the  gut  affected, 
and  finally  a  sudden  relaxation  with  loud  gurgling  sounds  in  the 
abdomen.  This  peristalsis  may  affect  either  circumscribed  or 
extensive  sections  of  the  intestine.  "When  the  abdominal  walls 
are  thin  the  motions  are  readily  perceived  with  the  unaided  eye. 

One  of  the  most  important  symptoms  of  stricture  of  the  bowel, 
and  at  the  same  time  the  most  important  sign  of  carcinoma,  is  the 
occurrence  of  palpable  and  visible  contractions.  It  is  difficult  in 
many  cases  to  tell  whether  these  movements  are  in  the  small  or 
in  the  large  bowel.  Occasionally  a  distinction  can  be  made  by 
examination  of  the  vagina  during  the  attack  of  pain  when  the  move- 
ments are  very  active.  Oftentimes  the  site  of  the  obstruction  may 
be  suspected  by  the  discovery  of  a  splashing  sound  in  the  bowel 
just  above  it.  One  peculiar  sign,  which  is  practically  pathogno- 
monic of  stenosis  of  the  bowel,  is  the  sudden  appearance  of  small 
coils  of  bowel  which  vanish  very  quickly  and  reappear.  The  section 
of  intestine  leading  to  the  obstruction  will  often  be  found  stiffly 
contracted. 

A  stricture  of  the  large  intestine  can  usually  be  made  out  by  the 
use  of  the  Roentgen  ray  (see  page  148).  The  bismuth  mixture 
should  be  introduced  by  rectal  injection  while  the  patient  lies  on 
his  back.  The  upward  passage  of  the  mixture  can  be  kept  under 
direct  inspection  with  the  fluoroscope.  In  the  study  of  constrictions 
of  the  large  intestine,  fluoroscopic  examination  during  the  flow  of 
the  bismuth  mixture  through  the  colon  is  more  valuable  than  roent- 
genograms. The  former  enables  us  to  study  the  motility  of  the 
intestine,  while  the  latter  show  only  single  momentary  phases  of 
the  position  of  the  filling  colon.     In  the  presence  of  constrictions 


758  STRICTURES  OF  THE  INTESTINE 

the  fluoroscopic  examination  shows  that  the  bismuth  stops  flowing 
at  the  site  of  the  obstruction.  There  is  usually  a  bulging  at  this 
point,  and  suddenly  a  finger-like  process  of  bismuth  passes  onward. 
It  is  possible  in  this  way  to  differentiate  between  tumors,  spasms 
and  adhesions  as  the  cause  of  the  stricture.  Anomalies  of  position, 
formation  of  loops,  dilatation  and  stenosis  of  the  lumen,  and  diver- 
ticulosis,  can  all  be  easily  recognized. 

Strictures  of  the  large  intestine  may  be  caused  by  adhesions 
(gynecologic  diseases,  former  operations)  and  subsequent  torsion, 
or  by  cicatricial  formations  (tuberculosis,  dysentery,  syphilis) 
involved  in  the  previous  history;  but  the  most  frequent  cause  is 
carcinoma. 

When  the  stenoses  persist  for  some  length  of  time,  they  may 
give  rise  to  the  formation  of  ulcers  of  distention  and  stercoral 
abscesses.  The  stenotic  portion  of  the  intestine  may  also  ulcerate 
on  the  interior  wall,  especially  in  the  presence  of  malignant  tumors. 
When  this  is  the  case  blood  and  pus  are  often  found  in  the  feces  in 
large  quantities,  so  that  an  examination  of  the  stools  at  first  seems 
to  point  to  dysentery. 

Treatment  of  Intestinal  Strictures.' — Strictures  of  the  intestine  that 
are  due  to  gallstones  or  swallowed  foreign  bodies  are  often  manage- 
able by  internal  treatment.  Other  intestinal  strictures  can  be  cured 
only  by  operative  treatment;  and  this  must  be  the  aim  of  any  sort 
of  therapeutic  intervention.  The  question  then  arises:  Which  are 
the  cases  suitable  for  operation?  Without  any  reservation,  all 
cases  of  malignant  stenosis  (carcinoma,  tuberculosis),  even  if  as  yet 
no  evil  effects  seem  visible,  belong  to  surgery;  also  all  those  cases  of 
benign  stenosis,  accompanied  by  grave  symptoms,  in  which  every 
kind  of  internal  treatment  has  been  in  vain.  Notwithstanding  the 
splendid  technic  of  modern  abdominal  surgery,  poor  results  are  often 
obtained  because  the  patients  are  very  anemic  and  cachectic — 
unable  to  survive  the  operation.  In  the  early  stages  of  the  disease 
most  patients,  unfortunately,  cannot  be  convinced  of  the  necessity 
of  an  operation.  Later  it  may  be  impossible  to  operate  because  of 
the  great  weakness  of  the  patient,  or  after  opening  the  abdomen 
such  complicated  anatomic  relations  may  be  disclosed  as  to  make  a 
radical  operation  impossible  or  even  forbid  a  palliative  operation. 
Matters  assume  the  worst  aspect  in  this  respect  in  cases  of  stenosis 
of  the  pars  superior  duodeni,  in  which  a  radical  removal  is  usually 
impossible.  There  may  be  some  hesitation  as  to  whether  it  is 
advisable  to  transfer  to  the  surgeon  cases  of  benign  stricture  which 
do  not  cause  any  grave  symptoms.  As  a  matter  of  principle  it  will 
probably  be  correct  to  advise  operation,  as  it  cannot  be  predicted 
in  any  case  whether  the  stenotic  trouble  will  remain  stationary  or 
become  worse.  An  exacerbation  of  the  whole  condition  may  some- 
times arise  quite  suddenly.  But  one  may  be  justified  in  undertak- 
ing internal  treatment  at  first,  so  long  as  it  is  certain  that  the 
stricture  is  not  of  a  malignant  character. 


STRICTURES  OF  THE  LARGE  INTESTINE  7.")!) 

The  internal  treatment  is  directed  to: 

1.  Curable  strictures  (calculi,  foreign  bodies). 

2.  Benign  strictures  with  slight  symptoms. 

3.  Malignant  strictures  in  which  operation  is  refused  by  the 
surgeon. 

In  regard  to  the  diet,  the  following  general  rules  apply  to  all 
cases  of  intestinal  stricture.  The  diet  must  be  of  such  a  nature 
that  it  will  pass  the  stricture — that  is  to  say,  absolutely  liquid  in 
grave  stenoses,  and  semisolid  in  cases  of  slight  stenosis.  It  should 
also  be  antiputrefactive.  The  feedings  should  be  only  large  enough 
to  provide  the  necessary  number  of  calories.  These  directions  must 
be  insisted  on  most  rigidly  in  stenoses  of  the  small  intestine.  In 
strictures  of  the  large  intestine  the  diet  may  be  somewhat  more 
liberal,  with  more  variety,  and  coarser  (see  page  174). 

In  stenoses  of  the  small  intestine  the  chief  article  of  diet  must 
be  milk,  which  should  be  made  antiseptic  by  the  addition  of  sali- 
cylic acid  (see  page  176).  Kefir,  yoghurt,  gruels  and  mucilaginous 
soups  are  permissible.  Various  leguminous  flour  soups,  with  addi- 
tions of  scraped  meat,  mashed  vegetables,  artificial  albuminous 
preparations,  and  plenty  of  butter,  oil  and  cream,  apple  sauce, 
mashed  potatoes,  wrell-softened  wheat  bread,  zwieback  and  biscuits, 
may  be  given. 

The  diet  in  strictures  of  the  large  intestine  differs.  Meat  may 
be  given  well  cut  up,  and  an  attempt  should  be  made  to  obtain,  if 
possible,  a  slightly  purgative  effect  by  utilizing  naturally  purgative 
articles  of  food,  such  as  fruit  juices,  honey,  fruit  acids,  and  jams 
of  various  fruits.  Great  stress  must  be  laid  on  the  fruit  being  of 
good  taste,  flavor  and  variety,  delicacies  being  used  freely.  The 
articles  altogether  prohibited  are:  fresh  fruit,  boiled  skin  and  seed 
fruit  (the  seeds  of  fruit  are  particularly  dangerous),  tendinous  meat 
containing  much  connective  tissue,  coarse  vegetables,  and  potatoes. 
The  careless  use  of  such  coarse  articles  of  food  occasionally  causes 
complete  closure  of  the  stenosis  and  other  grave  complications. 

When  the  nutrition  by  mouth  proves  inadequate,  careful  rectal 
feeding  must  be  instituted  (see  page  243). 

Strictures  of  the  small  intestine  situated  high  up  demand,  like 
stenoses  of  the  pylorus,  regular  lavage  of  the  stomach,  according 
to  the  principles  laid  down  for  stenosis  of  the  pylorus.  Rectal 
injections  are  required  in  all  cases  in  which  constipation  is  present 
or  in  which  it  alternates  with  diarrhea,  in  order  to  avoid  the  admin- 
istration of  purgatives.  In  such  cases  rather  voluminous  injections 
(one  liter)  are  to  be  used,  or  small-sized  enemata  retained  for  a 
long  time.  'When  the  strictures  of  the  colon  are  situated  low, 
medicated  lavage  or  irrigation  may  be  very  useful,  especially  when 
the  stenosis  is  ulcerating,  secreting  much  pus,  and  gives  rise  to 
hemorrhages.  In  such  cases  the  diseased  portion  is  to  be  cleansed 
very  gently  with  infusion  of  chamomile  and  subsequently  with  a 


760  STRICTURES  OF  THE  INTESTINE 

solution  of  borax  or  a  suspension  of  bismuth  subnitrate.  "When 
bismuth  subnitrate  is  introduced  by  irrigation  it  is  frequently 
possible  to  keep  the  formation  of  pus  and  mucus  and  the  loss  of 
blood  within  moderate  limits,  thus  favoring  the  general  well-being 
of  the  patient  (see  page  752). 

Medication. — The  purgatives  are  the  medicaments  particularly 
to  be  considered  here,  and  of  these  the  milder  ones  are  to  be  em- 
ployed, such  as  castor  oil,  cascara  sagrada,  phenolphthalein,  tama- 
rinds, and  the  bitter  mineral  waters,  in  rotation  but  continuously 
(see  page  284).  In  cases  of  stricture  of  the  large  intestine  with 
rigidity  of  the  intestinal  walls  the  anodynes  are  frequently  very 
effective  and  prompt  purgatives,  especially  opium  and  extract  of 
belladonna  in  the  form  of  suppositories  (see  page  274).  The  severe 
pains  often  require  the  above-named  anodynes,  and  also  morphin. 
In  hopeless  malignant  cases,  warm  applications  to  the  whole  of  the 
abdomen  are  grateful.  "When  the  suspicion  is  well  founded  that 
peritoneal  adhesions  are  the  cause  of  the  stenosis,  fibrolysin  treat- 
ment may  be  given  a  trial  (see  page  484). 

Strictures  due  to  calculi  and  foreign  bodies  should  be  treated 
by  means  of  purgatives.  Such  foreign  bodies  and  calculi,  when 
located  in  the  large  intestine,  can  frequently  be  loosened  by  skilfully 
applied  irrigations,  and  may  be  dissolved  by  appropriate  irrigating 
fluids  (see  Chapter  XI) . 

Liquid  petrolatum  has  been  used  to  lubricate  the  mucous  mem- 
brane of  the  intestine  and  thus  assist  the  gliding  along  of  the  feces. 
It  passes  through  the  whole  alimentary  canal  unchanged,  and 
frequently  affords  relief  in  cases  of  slight  stenosis.  I  have  seen 
the  marked  peristalsis  abate  and  normal  movements  ensue  when 
tablespoonful  doses  were  given  three  times  a  day  (see  pages  650 
and  664). 

When  it  is  impossible  to  relieve  these  strictures  by  internal 
medication,  it  becomes  absolutely  necessary  to  resort  to  surgical 
measures. 


CHAPTER  XLVIII. 

TUMORS  OF  THE  INTESTINE. 

Carcinoma;  Sarcoma;  Lymphosarcoma;  Adenoma;  Polypi; 
Lipoma;  Myoma. 

MALIGNANT  NEOPLASMS  OF  THE  INTESTINE. 

Carcinoma. — The  frequency  of  the  occurrence  of  carcinoma  of 
the  intestine  is  shown  by  statistics.  According  to  a  statistical 
statement  of  Heimann,  compiled  from  the  hospitals  in  Prussia, 
there  were,  among  a  total  of  20,544  cases  of  carcinoma,  1706  cases 
of  carcinoma  of  the  intestine  and  4288  of  carcinoma  of  the  stomach. 

Maydl  reports  that  of  41,838  necropsies  made  in  the  Pathologic 
Institute  at  Vienna  during  twenty-four  years,  alimentary  carcinomata 
were  present  in  3585  cases,  nearly  10  per  cent.  The  intestine  was 
involved  in  343  cases  as  follows:  the  rectum  in  162,  the  colon  in 
164,  the  ileum  in  10,  and  the  duodenum  in  7.  It  is  a  fact,  however, 
that  the  duodenum  becomes  carcinomatous  almost  as  frequently 
as  the  jejunum  and  the  ileum  together.  In  21,624  necropsies, 
Zemann  found  165  carcinomata  of  the  intestine,  8  per  cent,  of  the 
total  number. 

Carcinoma  is  most  frequent  in  the  large  intestine,  and  of  these 
cases,  according  co  Leube,  80  per  cent,  are  of  the  rectum  (Plate 
XXVIII) ;  then  follow,  in  order  of  frequency,  the  sigmoid  flexure, 
the  colon  (particularly  at  the  flexures),  and  the  cecum.  Car- 
cinoma of  the  small  intestine  is  comparatively  rare,  but  the  duo- 
denum is  more  frequently  involved  than  any  other  part  of  this 
region.  Female  and  male  are  attacked  in  about  equal  proportions, 
but  so  far  as  carcinoma  of  the  rectum  is  concerned  the  male  sex 
predominates.  Intestinal  carcinoma  occurs  most  frequently  be- 
tween the  ages  of  forty  and  sixty.  Occasionally  it  has  been  observed 
in  early  life  and  even  during  childhood. 

While  carcinoma  is  said  to  be  uncommon  in  some  countries,  in 
Japan  there  are  25,000  deaths  a  year  from  the  disease;  in  England 
it  is  estimated  that,  of  persons  over  thirty-five  years  of  age,  one 
out  of  every  eight  women  and  one  out  of  every  eleven  men  die  of 
carcinoma,  a  greater  death-rate  for  the  age  period  than  from  tuber- 
culosis; and  we  are  not  far  behind  in  this  country,  with  80,000  cases 
constantly  in  progress  and  over  40,000  deaths  each  year  from  the 
disease. 


762  TUMORS  OF  THE  INTESTINE 

Hollander  gives  some  interesting  family  histories  from  cases 
of  carcinoma  of  the  intestine,  which  show  a  most  striking  family 
tendency  to  carcinoma  in  some  form,  chiefly  of  the  gastro-intestinal 
tract.  In  the  first  case  the  husband  and  wife  (who  had  indistinct 
histories  of  carcinoma),  a  son  and  a  daughter  died  of  carcinoma; 
in  the  next  generation  four  children  died  of  the  disease,  in  the  next 
generation  two,  and  in  the  next  three.  In  another  instance  reported, 
one  case  occurred  in  one  generation,  four  in  the  next,  and  two  in 
the  next  ("generation"  including  the  collateral  branches  of  the 
family  as  well  as  the  direct  descendants).  He  considers  the  family 
history  a  very  important  point  in  the  diagnosis  of  carcinoma  of 
the  intestine,  since  it  seems  .to  be  intestinal  carcinoma  in  which 
these  striking  family  histories  are  most  commonly  met.  Another 
point  which  he  considers  of  much  importance  is  the  occurrence  of 
skin  changes,  chiefly  in  three  varieties:  (1)  vascular  changes;  (2) 
seborrheic  warts;  and  (3)  pigmental  patches.  The  vascular  changes 
consist  in  the  appearance  of  large  numbers  of  small  spots,  from 
the  size  of  a  pinhead  to  that  of  a  pea,  which  have  the  appearance 
of  small  angiomata.  The  warts  are  likely  to  occur  in  very  large 
numbers  and  may  reach  an  unusual  size.  He  has  seen  them 
as  large  as  pigeon's  eggs.  The  pigmented  areas  vary  in  appear- 
ance and  depth  of  color,  but  may  involve  practically  the  whole 
body.  These  signs  he  has  found  very  common  in  intestinal  car- 
cinoma. 

Pathology. — The  most  frequent  form  of  carcinoma  is  that  which 
consists  of  cylindric  epithelial  cells  originating  from  the  cylindric 
epithelium  of  the  mucous  membrane  and  showing  a  glandular 
structure.  Then  follows  the  medullary  carcinoma,  which  has  a 
tendency  to  disintegration  and  ulceration.  The  gelatiniform 
carcinoma  (colloid)  is  rare,  and  its  most  usual  location  is  in  the 
rectum.  Scirrhus  is  very  rare.  Intestinal  carcinomata,  as  a  rule, 
give  rise  to  few  metastases. 

Carcinoma  of  the  Small  Intestine.  —  Carcinomata  of  the  small 
intestine  are  rare  as  compared  with  similar  growths  of  the  large 
intestine.  The  carcinomata  of  the  duodenum  are  classified  as 
suprapapillary,  infrapapillary,  and  papillary.  The  location  of  the 
duodenal  papilla  (Vater),  an  elevation  near  the  point  where  the 
ductus  communis  choledochus  enters  the  duodenum,  is  used  for 
this  classification. 

If  a  tumor  is  present  in  the  suprapapillary  section  of  the  duo- 
denum, it  lies  to  the  right  of  the  median  line,  between  the  lower 
border  of  the  ribs,  the  navel  and  the  gall  bladder.  A  tumor  thus 
situated  will  be  found,  on  palpation,  to  be  easily  movable  >  If 
the  growth  arises  in  the  infrapapillary  section  of  the  duodenum, 
it  will  lie  in  the  same  position,  but  it  will  be  slightly  if  at  all  mov- 
able, being  firmly  fixed  by  the  pancreas  and  the  peritoneum.  The 
common  bile  duct  and  the  pancreatic  duct  perforate  the  median 


MALIGNANT  NEOPLASMS  OF  THE  INTESTINE  763 

border  of  the  papillary  section  of  the  duodenum.  It'  carcinoma 
develops  here,  the  opening  of  the  bile  duct  will  he  closed  and  jaundice 
will  result  (sec  page  614).  Growths  in  the  first  portion  of  the 
duodenum  are  similar  to  those  associated  with  ulcer  of  the  stomach. 
Those  of  the  papilla  are,  as  a  rule,  cylindric-cell  adenocarcinomata. 
Those  of  the  prejejunal  region  tend  to  be  broad,  flat  and  ulcerated, 
and  to  form  stenoses.  The  duodenal  contents  removed  with  the 
duodenal  tube  show  a  deviation  from  normal  of  the  pancreatic 
ferments  (see  page  103). 

Symptoms. — The  symptoms  of  snprapapillary  carcinoma  arfe: 
pains  in  the  region  of  the  stomach,  pressure,  nausea,  increasing 
emaciation,  lassitude,  and  the  appearance  of  a  tumor  in  the  right 
hypochondriac  region.  When  the  tumor,  as  a  consequence  of 
increasing  growth,  narrows  the  passage,  the  result  is  duodenal 
stenosis.  It  is  sometimes  scarcely  possible  to  establish  a  differential 
diagnosis  between  duodenal  stenosis  of  this  character  and  one  of 
different  origin.  Suprapapillary  and  infrapapillary  carcinomata 
offer  very  similar  appearances.  But  in  the  case  of  the  latter  the 
vomited  matter  is  stained  by  bile.  It  is  only  possible  to  diagnose 
such  a  case  when  a  tumor  is  palpable,  and  even  then  the  difficulties 
in  the  way  are  very  great.  Symptoms  of  stricture  are  also  mani- 
fested in  this  disease,  especially  toward  the  end. 

Of  particular  importance  respecting  papillary  carcinoma  is  the 
development  of  the  chronic  jaundice  without  demonstrable  disease 
of  either  the  liver  or  the  pancreas. 

Carcinoma  of  the  duodenum  is  usually  of  the  same  type  as 
carcinoma  of  the  pylorus.  The  growth  is  derived  from  a  simple 
form  of  secreting  cell,  cylindric  epithelium,  and  it  forms  a  new 
growth  of  cylindric  cells  arranged  in  a  manner  somewhat  similar 
to  that  of  the  normal  tissue  from  which  it  springs.  At  the  pylorus 
the  glands  are  formed  of  a  single  layer  of  cylindric  cells  on  a  base- 
ment membrane;  they  are  situated  in  the  mucous  membrane. 
At  the  junction  of  the  pyloric  end  of  the  stomach  and  the  duodenum 
the  glands  pass  down  through  the  muscularis  mucosa  into  the 
submucous  tissue,  and  in  the  duodenum  they  become  Brunner's 
glands.  The  pyloric  glands  and  Brunner's  glands  are  identical  in 
structure,  and  are  continuous  with  one  another;  the  only  difference 
is  as  to  situation,  one  being  in  the  mucous  membrane,  the  other  in 
the  submucosa. 

Diagnosis. — For  therapeutic  reasons  the  diagnosis  of  carcinoma 
of  the  duodenum  should  be  made  as  early  as  possible — a  task  that 
requires  the  keenest  medical  acumen.  In  the  majority  of  cases 
the  tumors  are  quite  large  when  discovered,  for  we  do  not  get 
many  symptoms  so  long  as  the  lumen  of  the  intestine  is  patulous. 

An  anatomic  peculiarity  of  intestinal  carcinoma  is  its  tendency 
to  develop  in  ring  form  and  to  traverse  the  inner  circumference  of 
the  intestine.     This  peculiarity  is  frequently  manifested,  and  in 


764  TUMORS  OF  THE  INTESTINE 

many  cases  very  marked.  Such  circular  formation  reduces  the 
lumen  of  the  intestine,  and  the  rapid  growth  and  tendency  to 
contraction  lead  to  a  stricture  that  calls  for  surgical  intervention. 
In  fact,  carcinoma  of  the  intestine  manifests  itself  by  the  phe- 
nomena of  stricture  (see  Chapter  XLVII). 

In  the  male  approximately  two-thirds,  and  in  the  female  one- 
fourth,  of  all  carcinomata  develop  in  the  alimentary  canal,  while 
one-half  of  all  carcinomata  of  the  female  are  in  the  reproductive 
organs.  It  seems  an  established  fact  that  carcinoma  of  the  duo- 
denum, while  very  rare,  usually  originates  from  a  previous  old 
duodenal  ulcer. 

Carcinomata  of  the  jejunum  and  ileum  are  also  rare  and  always 
difficult  to  diagnose,  particularly  if,  as  is  frequently  the  case,  no 
tumor  is  palpable.  Of  diagnostic  importance  in  regard  to  the 
presence  of  a  tumor  are  its  mobility,  the  symptoms  of  stenosis  of 
the  small  intestine,  and  hemorrhage  from  the  bowel.  The  Roentgen 
ray  is  frequently  of  great  help,  as  are  also  serologic  reactions  (see 
Plate  XVII,  Fig.  3,  and  page  543). 

Carcinoma  of  the  Colon. — Symptoms. — Particular  mention  must 
be  made  of  the  fact  that  among  the  subjective  symptoms  of  car- 
cinoma of  the  colon  intestinal  pains  are  most  conspicuous.  There 
may  be  a  permanent  dull  pain  localized  at  a  fixed  spot,  or  paroxys- 
mal abdominal  pains,  colicky  in  character,  which  are  very  charac- 
teristic and  may  persist  for  a  long  time,  even  years,  before  the 
development  of  any  other  sign  of  the  disease. 

These  painful  attacks  are  synchronous  with  constipation  and 
emesis.  The  more  intense  the  pains,  the  more  obstinate  the  con- 
stipation. The  painful  attack  ceases  after  a  free  evacuation  of 
the  bowel.  Occasionally  there  is  diarrhea,  especially  after  a 
constipated  period  of  several  days'  duration.  Vomiting  occurs 
early,  only  the  stomach  contents  and  mucus  being  ejected;  ster- 
coraceous  vomiting  occurs  less  frequently.  In  carcinoma  situated 
very  low  down,  particularly  rectal  carcinoma,  frequent  tenesmus 
is  the  most  prominent  symptom. 

Diagnosis. — The  objective  signs  important  for  diagnostic  pur- 
poses are:  the  presence  of  a  tumor  (which  is  found  in  40  per  cent, 
of  all  cases),  meteorism,  visible  peristaltic  movements,  rigidity  of 
the  intestine,  macroscopic  blood  from  the  bowels,  occult  hemorrhage 
in  the  feces,  diarrheic  stools  with  blood  and  pus,  anemia,  emaciation 
and  cachexia.  In  some  few  cases  all  these  criteria  may  be  absent; 
the  carcinoma  may  be  entirely  latent  and  either  terminate  fatally 
without  being  discovered  or  induce  a  sudden  attack  of  ileus.  A 
marked  loss  of  weight  (forty  or  fifty  pounds)  in  a  patient  over 
forty  years  of  age,  without  localization  of  symptoms,  is  always 
suggestive  of  hidden  carcinoma  of  the  intestine.  The  Roentgen- 
ray  examination  is  of  great  assistance  in  the  diagnosis.  Carcinoma 
of  the  large  intestine  may  be  complicated  with  perforation,  adhe- 


MALIGNANT  NEOPLASMS  OF  THE  INTESTINE  765 

sion  and  communication  with  the  abdominal  organs  (stomach, 
Madder),  or  perforation  through  the  abdominal  parietes  or  into  the 
retroperitoneal  tissues  with  formation  of  abscess  (Plate  XX,  Fig.  1). 

Attention  should  be  called  to  a  group  of  cases  which  are  frequently 
mistaken  for  malignant  growths.  Under  normal  conditions  we 
are  able  sometimes  to  feel  the  cord-like  descending  colon  or  the 
sigmoid  flexure,  which  may  be  tender  to  deep  palpation,  when  the 
abdominal  walls  are  thin  and  relaxed.  The  cord-like  feel  normally 
disappears  when  the  colon  is  emptied  or  inflated.  When  there 
are  no  symptoms  of  any  intestinal  disease  it  is  not  difficult  to 
diagnose  the  character  of  such  a  tumor-like  resistance.  It  is 
entirely  different  when  there  is  a  spastic  contraction  of  the  colon 
simultaneous  with  other  symptoms,  such  as  constipation,  irregular 
movements,  pain,  and  disturbance  of  the  general  condition.  Under 
such  circumstances  we  are  likely  to  suspect  a  malignant  growth, 
when  the  condition  is  one  of  spastic  constipation  (see  Chapter 
XXXVII).    Such  spasms  occur  as  a  pure  neurosis. 

Treatment. — Carcinoma  of  the  intestine  cannot  be  cured  by 
internal  remedies;  a  radical  recovery  can  only  be  brought  about 
by  surgical  treatment.  Operative  therapeutics,  however,  is  often 
unsuccessful,  for  a  variety  of  reasons.  The  diagnosis  is  usually 
made  too  late,  at  a  time  when  the  carcinoma  has  attained  a  large 
size,  metastases  have  developed,  and  operative  removal  is  no  longer 
possible.  Operation  is  often  prevented  by  the  objections  offered 
by  the  patients  and  their  friends,  although  the  diagnosis  may  have 
been  established  in  time.  Moreover,  the  radical  operation  is  fre- 
quently a  severe  proceeding,  and  the  patient,  already  considerably 
weakened,  is  unable  to  survive  it. 

The  radical  operation  therefore  is  a  -priori  contra-indicated  in 
the  presence  of  marked  cachexia  and  anemia,  and  when,  as  shown 
by  the  clinical  examination,  metastases,  adhesions  of  the  tumor 
and  other  complications  are  present.  In  these  cases  a  palliative 
operation  is  indicated,  especially  when  symptoms  of  stenosis  and 
ileus  have  appeared.  The  radical  operation  consists  in  total 
resection  of  the  carcinomatous  portion  of  the  gut.  The  palliative 
operation  is  the  establishment  of  an  artificial  anus;  the  radical 
operation,  separation  of  the  diseased  portion  of  the  gut  by  resection 
of  the  intestine  above  and  below  the  carcinoma,  and  joining  of  the 
intestinal  ends  by  anastomosis.  The  mortality  in  the  resections  is 
50  per  cent.,  with  about  three  years  of  life  after  the  operation. 
Some  permanent  recoveries  have  followed  the  radical  resection. 

At  the  International  Congress  of  Medicine  held  in  London,  1913, 
Bastianelli  of  Rome  read  a  paper  on  the  operative  treatment  of 
malignant  disease  of  the  large  intestine,  in  which  he  gave  the  follow- 
ing summary,  the  cases  having  been  collected  from  the  data  of  a 
few  surgeons  of  wide  experience:  Total  number  of  cases  operated 
on  more  than  three  years  ago,  239;  operative  cures,  140;  alive  and 


766  TUMORS  OF  THE  INTESTINE 

well  three  years  after,  68 — 42.8  per  cent,  of  the  survivors  from  the 
operation,  or  28.8  per  cent,  of  all  cases  operated  upon. 

The  internal  treatment  coincides  in  all  its  essential  points  with 
the  therapeutics  adopted  in  cases  of  stricture  and  of  ulcer.  The 
aim  is  to  increase  the  disease-resisting  powers  of  the  patient  as 
much  as  possible  by  dietetic  measures  and  to  render  life  tolerable 
by  mitigation  of  the  pains.  The  former  object  is  attained  by  a 
diet  arranged  in  accordance  with  the  situation  of  the  carcinoma 
(large  or  small  intestine) ;  the  latter  by  the  administration  of  ano- 
dynes and  narcotics.  Lavage  of  the  stomach  and  irrigation  of 
the  intestine  are  sometimes  indicated. 

Sarcoma  and  Lymphosarcoma  of  the  Intestine. — In  contra- 
distinction to  carcinomata,  sarcomata  and  lymphosarcomata  of  the 
intestine  are  of  very  rare  occurrence;  they  are  found  particularly 
between  the  ages  of  ten  and  forty.  As  a  rule  they  are  situated  in 
or  on  the  small  intestine  or  the  rectum. 

In  respect  to  the  pathologic  anatomy,  all  kinds  of  sarcomata 
may  be  present.  The  ones  most  frequently  found  are  the  round- 
cell  and  spindle-cell  variety.  They  originate  from  the  submucous 
or  subserous  coat  and  are  generally  smooth  tumors.  They  are 
distinguished  from  carcinoma  by  their  very  rapid  growth,  and  may 
develop  into  tumors  of  enormous  size. 

The  starting  point  of  lymphosarcoma  is  in  the  lymphatics  of 
the  intestine.  Like  sarcomata,  these  growths  often  cover  extensive 
areas  of  the  intestinal  tract,  and  in  consequence  of  the  tissue  meta- 
morphosis the  affected  portion  of  the  intestine  becomes  a  rigid 
tube,  of  large  lumen,  without  stenosis. 

Symptoms. — Clinically,  sarcoma  or  lymphosarcoma  may  be 
suspected  when  no  symptoms  of  stenosis  are  found  though  large 
tumors  are  present.  The  cachexia  supervenes  more  rapidly  than 
in  carcinoma;  edema,  ascites,  and  metastases  in  the  peritoneum 
are  also  sooner  developed.  The  lifeperiod  of  the  patient  after 
sarcoma  or  lymphosarcoma  makes  its  appearance  is  consideraby 
shorter  than  in  cases  of  carcinoma. 

Treatment. — In  inoperable  cases  temporary  cessations  and  amelio- 
rations are  sometimes  effected  by  treatment  with  arsenic;  and  cures 
have  been  reported  from  the  mixed  toxin  treatment  as  employed 
by  Dr.  Goley,  o|  the  New  York  Cancer  Hospital — the  toxins  of 
Streptococcus  erysipelatis  and  Bacillus  prodigiosus  injected  hypo- 
dermically  in  doses  of  I  to  §  minim  and  upward. 

BENIGN  NEOPLASMS  OF  THE  INTESTINE. 

The  benign  growths  that  develop  in  the  intestine  are  adenomata, 
polypi,  lipomata  and  myomaia.  After  the  diagnosis  has  been 
established  the  treatment  must  be  exclusively  suigical. 


CHAPTER  XLIX. 
APPENDICITIS. 

Appendicular  Inflammation  —  Circumscribed    Peritonitis  — 

1*i;kl  rv  i'ii  litis— Paratyphlitis — Scolecoiditis — Scolecitis. 

ACUTE  APPENDICITIS. 

Appendicitis  is  an  inflammation  of  the  appendix  vermiformis. 
Acute  appendicitis  is  an  infectious  disease,  induced 'by  bacteria 
which  enter  either  from  the  intestinal  canal  (enterogenous  route) 
or  through  the  circulation  (hematogenous  route).  The  infection 
may  rapidly  subside,  or  it  may  attack  the  entire  appendix  and 
involve  the  peritoneum.  The  appendix  is  exposed  to  all  the  diseases 
of  the  intestine,  particularly  catarrhal  affections;  the  enterogenous 
transmission  of  the  pathogenic  agents  is  easy.  When,  in  conse- 
quence of  catarrhal  conditions,  the  mucous  membrane  of  the 
appendix  becomes  swollen,  communication  with  the  cecum  is 
obstructed,  the  secretions  stagnate  behind  the  obstruction,  and  the 
imprisoned  bacteria  set  up  an  inflammatory  process.  A  similar 
condition  may  result  from  fecal  concrements  (enteroliths),  from 
angular  bending  of  the  appendix,  from  stenoses  in  the  appendicular 
lumen,  from  abnormal  length  or  position  of  the  appendix,  from 
adhesions,  or  from  swelling  of  the  lymphatic  elements  of  the  appen- 
dix. Appendicitis  may  develop  through  the  hematogenous  route 
from  infectious  diseases  and  in  connection  with  osteomyelitis, 
enteric  fever,  dysentery,  tonsillitis,  furuncles,  influenza,  or  oral 
sepsis  (see  page  290).  It  is  often  secondary  to  tonsillar  or  dental 
infection.  The  character  of  the  bacteria,  which  are  usually  strep- 
tococci, is  altered  by  their  growth  in  the  mouth,  so  that  they  have 
an  affinity  for  appendicular  tissue.  The  streptococci  which  inhabit 
the  gastro-intestinal  tract  do  not  possess  this  affinity. 

Pinworms  are  prone  to  invade  the  appendix  from  their  habitat 
in  the  cecum  and  may  induce  appendicitis  (see  page  803).  Accu- 
mulating in  the  appendix  in  such  numbers  that  they  block  the 
lumen,  violent  expulsive  contractions  result,  furnishing  the  clinical 
picture  of  appendicular  colic.  Relief  follows  a  partial  emptying 
of  the  appendix  by  means  of  these  contractions,  and  the  colicky 
attack  is  not  repeated  until  the  appendix  is  again  distended. 
Worms  of  various  kinds  have  on  many  occasions  been  found  within 
the  appendix.  Cases  are  reported  where  worms  were  found  fixed 
to  the  mucous  membrane,  and  even  embedded  in  the  parietes. 


768  APPENDICITIS 

Attention  was  long  since  called  to  the  relationship  between 
appendicitis  and  visceral  ptosis.  Glenard  has  discussed  gastro- 
enteroptosis  in  this  connection  (see  Chapter  XXX).  Edebohls 
believes  that  from  80  to  90  per  cent,  of  women  who  have  movable 
right  kidney  have  chronic  appendicitis  also.  This  frequency 
renders  chronic  appendicitis  one  of  the  chief  symptoms  of  movable 
kidney;  and  in  view  of  the  protracted  suffering  and  serious  impair- 
ment of  health  which  it  entails,  and  the  dangerous  possibilities  of 
concurrent  acute  attacks,  it  may  be  considered  the  most  important 
complication  of  movable  right  kidney. 

Two  varieties  of  the  disease  are  recognized — simple  acute  appen- 
dicitis and  destructive  appendicitis. 

Simple  acute  appendicitis  is  nearly  always  a  catarrhal  affection 
of  the  mucous  membrane  of  the  appendix,  spreading  to  the  adjacent 
intestine.  As  a  rule  the  peritoneum  does  not  participate,  but 
sometimes  the  serous  covering  is  slightly  affected.  In  this,  the 
lightest  form  of  appendicitis,  the  mucous  membrane  and  the 
follicles  are  swollen  and  covered  with  mucus  and  secretions,  show- 
ing small  hemorrhages  and  erosions.  When  the  secretions  escape 
into  the  cecum  the  process  may  recede;  but  when  this  does  not  take 
place  there  may  develop  a  phlegmonous  inflammation  of  the 
appendix  with  deep  ulceration  and  moderately  intense  fibrinous 
peritonitis.  This  stage  may  undergo  resolution  with  retrogression 
of  the  inflammation  and  the  establishment  of  an  open  lumen.  The 
alterations  in  the  appendix  after  the  inflammation  may  be  very 
slight,  such  as  small  cicatrices  and  thickening  of  the  walls,  or 
obstructions  and  strictures  may  develop  which  will  later  cause 
relapses.  When  the  phlegmonous  process  is  not  arrested,  destruc- 
tive appendicitis  is  established,  with  ulceration,  empyema  and  gan- 
orene,  leading  to  perforation.  Perforation  is  succeeded  either  by 
an  appendiceal  abscess  or  by  the  development  of  a  general  purulent 
peritonitis,  depending  upon  the  protective  adhesions  formed  between 
the  peritoneum  and  the  intestine. 

The  cecum  is  a  region  in  which  intestinal  stasis,  within  certain 
limits,  is  normal,  and,  because  of  this,  the  lymphadenoid  tissue 
is  abundant.  In  the  vermiform  appendix  the  same  condition 
exists  but  in  an  exaggerated  form*,  and  here  the  lymphoid  tissue  is 
the  chief  characteristic.  When  there  is  a  swelling  of  the  mucous 
membrane  (edema,  catarrhal  inflammation)  of  the  cecum,  the 
normal  process  of  emptying  the  appendix  is  retarded,  due  to  the 
narrowing  of  the  aperture  into  the  cecum,  and  abnormal  appendicu- 
lar stasis  occurs.  Under  such  circumstances  the  lymphoid  tissue 
increases,  the  nodes  swell,  and,  if  the  organisms  taken  up  by  them 
are  pus-producers,  suppurative  appendicitis  results. 

Symptoms. — In  cases  of  simple  acute  appendicitis  the  symptoms 
rapidly  subside  in  conformity  to  the  pathologic  course  described 
above,  and  for  this  reason  the  entire  process  may  disappear  in 


ACUTE    \rrr:\  DICITIS  769 

two  or  three  days.  But  when  the  anatomic  alterations  in  the 
appendix  are  progressive,  the  clinical  symptoms  likewise  increase 
in  gravity.  The  greater  the  pathologic  change,  the  more  the 
symptoms  of  destructive  appendicitis  and  of  general  septic  infection 
become  evident.  These  progressive  symptoms  include  a  feeling  of 
intense  malaise,  a  greatly  disturbed  general  condition,  an  anxious, 
drawn  facial  expression,  great  weakness,  frequent  vomiting,  and 
fever.  The  disturbance  in  the  general  condition  depends  espe- 
cially upon  the  virulence  of  the  infective  agents.  At  the  same  time 
the  local  symptoms  become  aggravated  in  a  corresponding  manner. 
The  pains  may  be  very  severe,  and  McBurney's  point  so  sensitive 
that  the  lightest  touch  is  almost  intolerable. 

In  most  of  the  cases  there  is  a  marked  degree  of  cutaneous 
hyperesthesia.  In  acute  inflammation  of  the  appendix  absence  of 
pain  is  no  indication  that  the  most  serious  mischief  is  not  going 
on;  the  initial  pain  of  acute  inflammation  of  the  appendix,  which 
is  so  commonly  referred  to  the  umbilicus,  is  due  to  the  dragging 
upon  the  mesocecum  or  the  mesoappendix.  The  cessation  of  this 
pain  without  improvement  in  the  other  symptoms  is  due  to  cessa- 
tion of  peristalsis,  a  result  of  the  spreading  of  the  inflammation. 
Severe  pain  is  of  great  importance,  as  it  implies  either  wide  extent 
or  great  severity  of  inflammation.  Sudden  cessation  of  the  pain 
without  corresponding  general  improvement  suggests  that  the 
appendix  has  become  gangrenous. 

When  an  abscess  has  fully  formed,  a  tumor  can  be  made  out 
above  Poupart's  ligament;  the  tumor  can  be  palpated  from  the 
rectum  or  the  vagina,  and  this  procedure  should  never  be  omitted. 
Increased  muscular  rigidity  (defense  musculaire)  over  the  region 
of  the  cecum  should  be  particularly  noted  as  indicating  the  involve- 
ment of  the  peritoneum.  There  may  also  be  increased  subjective 
and  objective  tenderness  extending  into  the  left  side  of  the  abdomen 
and  into  the  lumbar  region. 

If  the  appendix  lies  retrocecally,  an  abscess  may  develop  in  the 
lumbar  region,  which  sometimes  reaches  up  to  the  lower  pole  of 
the  kidney  or  the  hilus  of  the  liver.  This  condition  can  often  be 
recognized  by  protrusion  or  resistance  in  the  loin  just  above  the 
iliac  crest.     This  spot  is  also  the  main  seat  of  pain  upon  pressure. 

There  is  an  increased  leukocytosis,  accompanied  by  high  fever 
and  rapid  pulse.  In  grave  cases  watery  diarrhea  is  frequently 
present.  The  absence  of  a  perityphlitic  tumor  when  there  are 
severe  general  symptoms  points  to  the  probability  that  the  pus 
has  not  become  walled  off.  When  general  peritonitis  is  well  estab- 
lished, it  shows  its  own  characteristic  symptoms  in  gaseous  dis- 
tention, paralysis  of  the  intestine,  diffuse  sensitiveness  to  pressure 
upon  the  abdomen,  and  collapse. 

Diagnosis. — The  commencement  of  simple  acute  appendicitis  is 
nearly  always  rather  sudden,  marked  by  more  or  less  pain  in  the 
49 


770  APPENDICITIS 

region  of  the  appendix,  nausea,  and  vomiting.  Chills  are  often 
present.  The  bowels  are  usually  constipated,  but  sometimes  loose. 
There  is  fever,  with  acceleration  of  the  pulse.  Pain  at  McBurney's 
point  is  elicited  upon  pressure.  This  is  important,  and  a  detail  of 
the  location,  as  stated  by  McBurney,  is  herewith  given: 

"Whatever  may  be  the  position  of  the  healthy  appendix  as  found 
in  the  dead-house  (and  I  am  well  aware  that  its  position  when 
inflamed  varies  greatly),  I  have  found  in  all  my  operations  that  it 
lay,  either  thickened,  shortened  or  adherent,  very  close  to  its 
attachment  to  the  cecum. 

"This,  of  course,  must  in  the  early  stages  of  the  disease  determine 
the  seat  of  greatest  pain  on  pressure,  and  I  believe  that  in  every 
case  the  seat  of  greatest  pain,  determined  by  the  pressure  of  one 
finger,  has  been  exactly  between  an  inch  and  a  half  and  two  inches 
from  the  anterior  superior  spinous  process  of  the  ilium  on  a  straight 
line  drawn  from  that  process  to  the  umbilicus." 

While  exerting  pressure  over  McBurney's  point,  the  elevation  of- 
the  right  leg  of  the  patient  contracts  the  psoas  muscle  and  forces 
the  painful  appendix  against  the  finger.  For  this  valuable  sign, 
which  often  assists  in  a  differential  diagnosis,  we  are  indebted  to 
S.  J.  Meltzer. 

Bluniberg's  sign,  which  consists  of  a  short  acute  pain  felt  by 
the  patient  when  the  examiner's  finger  is  pressed  over  McBurney's 
point  and  lifted  up  suddenly,  is  usually  present.  This  sign  occurs 
in  all  forms  of  acute  peritoneal  inflammation. 

Blaisdell  emphasizes  the  importance  of  the  turning  test  in  the 
diagnosis  of  acute  appendicitis.  He  found  that  in  cases  of  suspected 
acute  appendicitis  the  patient  will  nearly  always  be  found  lying 
either  on  the  back  or  on  the  right  side,  pain  being  experienced  when 
he  turns  on  the  left  side.  This  holds  good  in  90  per  cent,  of  all 
cases.  Even  if  other  symptoms  are  absent  Blaisdell  believes  that 
turning  on  the  left  side  is  a  positive  test.  In  making  the  test  the 
abdomen  must  not  be  allowed  to  touch  the  bed,  lest  the  support 
thus  given  to  the  viscera  prevent  the  additional  pain  which  results 
from  the  dragging  on  the  sensitive  appendix. 

In  the  male,  traction  on  the  right  spermatic  cord  induces  severe 
pain  near  the  internal  abdominal  ring,  due  to  irritation  of  the 
parietal  peritoneum.  The  cord  is  to  be  grasped  between  the  thumb 
and  index  finger,  above  the  testicle,  care  being  exercised  not  to 
press  unnecessarily  on  the  latter. 

On  the  whole  the  diagnosis  of  appendicitis  is  not  difficult.  In 
considering  the  differential  diagnosis,  attention  should  be  given  to 
diseases  of  the  female  organs,  to  enteric  fever,  to  diseases  of  the 
gall  bladder,  and  to  the  pseudo-appendicitis  of  hysteria.  A  movable 
cecum  is  occasionally  found  as  a  complication  of  appendicitis. 
This  condition,  known  as  cecum  mobile,  which  in  itself  may  give 
pain  similar  to  that  of  appendicitis,  is  caused   by  a   congenital 


CWtoXlC   Al'l'KSDICITia  7/  I 

malformation  of  the  mesocolon  of  the  cecum.  For  some  distance 
the  mesentery  is  not  attached  to  the  parietal  peritoneum,  and  this 
permits  freedom  of  movement  and  displacement.  It'  the  patient 
stands,  the  pain  is  more  severe,  bul  it  is  quickly  relieved  by  lying 

on  the  hack  or  on  the  right  side.  Chronic  constipation  that  docs 
not  respond  to  laxatives  is  suggestive  of  cecum  mobile.  The 
Roentgen  ray  shows  that  the  bismuth  remains  in  the  cecum  for 
two  or  three  days  (sec  page  147). 

Occasionally  the  lymph  nodes  of  the  mesentery  in  the  cecal  region 
will  become  infected,  giving  the  clinical  symptoms  of  an  acute 
appendicitis.  The  source  of  the  infection  is  usually  within  the 
appendix,  so  that  the  treatment  of  right  inguinal  mesenteric 
lymphadenitis  is  the  surgical  removal  of  the  appendix. 

Absence  of  fever,  multiplicity  of  the  painful  spots,  cutaneous 
hyperesthesia,  the  contrast  that  exists  between  the  state  of  the 
general  health  (which  is  good)  and  the  local  symptoms  (which  are 
very  pronounced) — these  together  would  justify  rejecting  the 
diagnosis  of  appendicular  lesion.  If  there  is  merely  abdominal 
neuralgia  we  shall  discover  the  classical  pain  spots,  and  treatment 
will  clear  up  any  lingering  doubt. 

Great  difficulty  is  occasionally  experienced  in  forming  a  clear 
picture  of  the  anatomic  conditions  at  every  stage  of  appendicitis. 
For  it  may  happen  in  some  cases  that  notwithstanding  the  exist- 
ence of  a  most  severe  destructive  appendicitis  the  symptoms  present 
are  slight,  or  vice  versa.  The  typical  appendicular  symptoms  may 
sometimes  become  localized  in  the  left  iliac  fossa,  especially  when 
the  appendix  is  very  long  or  when  it  is  transposed  toward  the  left. 
This  condition  must  not  be  mistaken  for  acute  perisigmoiditis  and 
diverticulitis  (see  page  785),  which  have  all  the  symptoms  of  an 
acute  left-sided  appendicitis. 

CHRONIC  APPENDICITIS. 

Acute  appendicitis  can  only  be  considered  entirely  cured  when 
the  pathologic  changes  in  the  appendix  have  disappeared  and  the 
lumen  has  not  been  left  stenotic.  Stricture  is  a  very  frequent 
sequela,  and  offers  a  rational  explanation  of  the  great  frequency 
of  relapses. 

Symptoms. — The  course  of  chronic  appendicitis  may  be  such 
that  the  primary  acute  attack  is  followed  by  numerous  recur- 
rences. The  latter  may  vary  greatly  in  intensity,  from  the  slightest 
colicky  pains  of  but  a  few  hours'  duration  (caused  by  the  appendix 
attempting  to  push  its  contents  into  the  cecum)  to  the  most  severe 
attacks.  As  a  rule  the  subsequent  pains  are  less  severe  than  the 
first  acute  seizure.  The  course  may  be  such  that  no  acute  attack 
has  been  noted  at  all,  but  the  patients  constantly  complain  of  pains 
in  the  region  of  the  appendix,  particularly  during  bodily  movements, 


772  APPENDICITIS 

on  stooping,  lifting,  or  while  at  stool.  These  cases  of  appendicitis 
running  an  insidious  course  without  acute  attacks  are  usually 
benign,  although  they  inconvenience  the  patients  greatly.  Another 
variety  is  that  in  which  painful  sensations  remain  in  the  cecal 
region  after  a  single  acute  attack,  without  an  acute  recurrence  at 
any  time.  The  name  "appendicitis  larvata"  has  been  applied  to 
a  concealed  chronic  form  with  symptoms  pointing  to  disease  of 
the  gas'tro-intestinal  tract  and  frequently  mistaken  for  nervous 
dyspepsia  or  intestinal  catarrh  (see  page  427). 

Ewald  was  the  first  to  throw  light  upon  this  subject.  He  pre- 
sented a  number  of  cases  which  he  termed  collectively  appendicitis 
larvata,  or  masked  appendicitis  (see  page  419).  The  cases  had 
many  of  the  obscure  dyspeptic  symptoms  which  are  sometimes 
classed  as  belonging  to  nervous  dyspepsia.  None  of  the  patients 
gave  a  history  of  appendicitis,  yet  it  was  possible  by  careful  palpa- 
tion to  diagnose  chronic,  subjectively  unnoticed,  appendicitis. 
Appendicitis  larvata  presents  no  characteristic  symptoms,  and  the 
diagnosis  can  be  made  only  by  excluding  diseases  of  the  gall  blad- 
der, stomach,  and  pelvis,  and  by  means  of  the  Roentgen  ray  (see 
Chapter  Y)  and  the  positive  objective  findings. 

Diagnosis. — Rovsing  describes  a  sign  that  is  important  as  a 
differential  diagnostic  point.  It  consists  of  pain  in  the  appendiceal 
region  following  pressure  upon  the  left  side.  This  symptom  is 
not  met  with  in  kidney  diseases,  ureteritis,  stones  in  the  ureter,  or 
salpingitis;  but  only  in  diseases  of  the  appendix  and  cecum.  The 
procedure  consists  in  placing  the  fingers  of  the  left  hand  flatly  upon 
the  abdomen  and  pressing  slowly  down  with  the  right  hand  along 
the  brim  of  the  pelvis  into  the  left  iliac  fossa,  so  that  the  coils  of 
the  ileum  are  pushed  inward  out  of  the  way  and  the  fingers  press 
the  descending  colon  firmly  against  the  posterior  abdominal  wall. 
The  fingers  that  firmly  compress  the  descending  colon  are  now 
moved  slowly  upward  toward  the  splenic  flexure.  By  this  manipu- 
lation the  contents  of  the  gut  are  put  under  high  enough  tension 
to  effect  a  back  pressure  upon  the  cecum.  By  this  pressure  a 
severe  lightning-like  pain  is  produced  in  the  ileocecal  region.  Chase 
has  applied  the  term  "cecal  distention  test"  to  this  procedure; 
he  believes  that  a  gaseous  compression  wave  will  travel  across  the 
transverse  and  down  the  ascending  colon  and  on  arriving  at  the 
cecum  will  produce  cecal  distention,  yielding  a  typical  sharp  pain 
in  the  right  iliac  fossa,  if  inflammation  of  the  cecum  or  appendix 
be  present. 

Rutkevich  recommends  exploration  of  the  cecum  by  adduction. 
The  flexed  fingers  of  the  right  hand  are  worked  between  the  external 
wall  of  the  cecum  and  the  abdominal  wall;  then  by  extending  the 
fingers  the  examiner  tries  to  push  the  cecum  toward  the  median  line 
of  the  abdomen.  In  case  of  chronic  appendicitis  this  will  cause 
pain. 


CHRONIC  APPENDICITIS  i  73 

Bastedo  recommends  the  dilatation  test  for  chronic  appendicitis. 

To  make  this  test,  a  colon  tube  is  passed  a  few  inches  into  the  rec- 
tum, and  air  is  injected  by  means  of  an  atomizer  bulb.  If,  as  the 
colon  distends,  pain  and  tenderness  to  finger-point  pressure  become 
apparent  at  McBuruey's  point,  there  is  chronic  appendicitis. 

Morris  has  found  by  pressure  a  painful  point  on  McBurney's 
line,  an  inch  and  a  half  from  the  umbilicus,  which  is  especially 
sensitive  in  chronic  appendicitis.  The  sensitiveness  and  pain  appear 
to  he  due  to  an  irritation  of  the  right  sympathetic.  When  the 
irritation  originates  from  a  pelvic,  tubal,  uterine  or  hemorrhoidal 
affection,  one  observes  two  corresponding  painful  points,  one  on 
each  side  of  the  umbilicus. 

Aaron 's  Sign.1 — This  consists  of  a  referred  pain  or  distress  in 
the  epigastrium,  left  hypochondrium,  umbilical,  left  inguinal  or 
precordial  region  from  continuous  firm  pressure  over  the  appendix. 
I  have  found  this  sign  exceedingly  valuable  in  deciding  when  and 
when  not  to  recommend  operation  for  chronic  appendicitis.  The 
test  has  been  repeatedly  confirmed  by  operation  and  it  is  usually 
found  in  such  cases  that  the  appendix  is  distorted,  adherent,  or 
contracted.  The  referred  pain  in  these  cases  is  due  to  spasm  of 
the  pylorus  or  duodenum.2 

Transitional  leukocytosis  or  an  increase  in  large  mononuclears 
and  in  transitional  leukocytes  is,  according  to  Friedman,  suggestive 
of  chronic  appendicitis. 

Treatment  of  Acute  Appendicitis. — The  ideal  treatment  of  acute 
appendicitis  is  operation  within  the  first  twenty-four  to  thirty-six 
hours  after  the  onset  of  the  disease.  This  represents  today  the 
best  therapeutic  endeavor  for  the  treatment  of  acute  appendicitis. 
It  radically  removes  the  disease  and  cures  the  patient  in  the  shortest 
possible  time. 

Guerry  reports  a  mortality  rate  of  0.3  per  cent,  in  a  series  of 
545  appendicular  operations.  He  says  the  third-  and  fourth-day 
acute  cases  are  the  ones  that  die.  There  is  a  definite  and  unmis- 
takable tendency  toward  localization  in  cases  of  appendicitis  com- 
plicated by  the  presence  of  pus.  In  this  series  of  545  there  were 
213  of  this  variety — a  very  large  proportion.  Of  these  213  cases, 
68  patients  were  seen  for  the  first  time  on  the  third  or  fourth  day 
of  the  disease.  The  pulse  in  most  cases  was  135,  temperature 
104°  F.;  vomiting,  distention,  pinched  features  and  more  or  less 
delirium  were  also  present.  Such  cases  as  these  are  the  ones  in 
which  operation  is  attended  with  mortality.  None  of  these  patients 
were  operated  upon  immediately;  all  were  treated  according  to  the 
Ochsner  method;  they  were  tided  through  the  period  of  great 

1  Charles  D.  Aaron,  A  Sign  Indicative  of  Chronic  Appendicitis,  Journal  of  the 
American  Medical  Association,  February  1,  1913. 

2  Charles  D.  Aaron,  Chronic  Appendicitis,  Pylorospasm  and  Duodenal  Ulcer, 
Journal  of  the  American  Medical  Association,  May  29,  1915,  p.  1845. 


774  APPENDICITIS 

danger,  and  several  days  later  were  safely  operated  upon  for  local- 
ized appendicular  abscess. 

The  Ochsner  method  has  been  greatly  misunderstood  by  the 
profession;  when  properly  applied  it  is  a  life-saving  measure  and 
entitled  to  the  highest  consideration.  It  was  never  intended  that 
it  should  take  the  place  of  operation,  but  that  it  should  permit  the 
selection  of  a  safe  time  for  operation.  In  cases  in  which  the  patients 
or  their  friends  absolutely  refuse  an  operation  the  pharynx  should 
be  promptly  cocainized,  and  the  patient's  stomach  irrigated  (through 
the  stomach  tube)  with  warm  normal  salt  solution;  then  food  and 
cathartics  by  mouth  should  be' forbidden  until  the  patient  has  been 
normal  for  four  days,  nutrition  in  the  meantime  being  effected 
by  means  of  enemata  every  three  or  four  hours,  consisting  of  some 
concentrated  liquid  food  dissolved  in  three  ounces  of  normal  salt 
solution. 

Ochsner's  method  of  treatment  to  reduce  mortality  involves  the 
following  suggestions:  In  chronic  recurrent  appendicitis,  operation 
during  the  interval  between  attacks.  In  acute  appendicitis, 
operation  as  soon  as  the  diagnosis  is  made,  provided  the  infectious 
material  is  still  confined  to  the  appendix,  and  a  competent  surgeon 
is  available.  In  acute  appendicitis  and  in  peritonitis,  without 
regard  to  the  treatment  contemplated,  food  and  cathartics  by 
mouth  to  be  absolutely  prohibited  and  large  enemata  never  given. 
To  relieve  nausea,  vomiting,  or  gaseous  distention  of  the  abdomen 
— gastric  lavage.  When  the  infection  has  extended  beyond  the 
appendix,  watch  and  sustain  the  patient  until  operative  intervention 
is  safe.  At  the  beginning,  let  the  thirst  be  quenched  by  rinsing 
the  mouth  with  cold  water  and  by  the  use  of  small  enemata.  Later 
small  sips  of  very  hot  water  frequently  repeated  may  be  allowed, 
and  still  later  small  sips  of  cold  water. 

All  these  cases  are  greatly  benefited  by  normal  salt  solution, 
given  by  the  Murphy  drip  (see  page  239) .  It  should  be  constantly 
borne  in  mind  that  even  the  slightest  amount  of  liquid  food  of  any 
kind  by  mouth  may  give  rise  to  dangerous  peristalsis  and  may 
change  a  harmless  (circumscribed)  into  a  dangerous  (diffuse) 
peritonitis. 

This  treatment  is  always  indicated,  without  regard  to  whether 
an  immediate  operation  is  or  is  not  contemplated.  The  physician 
should  be  on  his  guard  against  erroneous  deductions  from  the  very 
rapid  improvement  of  apparently  serious  cases;  there  may  be,  after 
all,  gangrene  or  perforative  appendicitis,  which  would  render  pre- 
mature feeding  fatal. 

Surgeons  and  physicians  do  not,  however,  agree  in  respect  to  the 
question  of  whether  the  lighter  and  milder  cases  should  always  be 
operated  upon  immediately,  or  whether  it  is  proper  to  treat  them 
expectantly  pending  the  development  of  serious  symptoms.  Many 
physicians  maintain  that  in  cases  taking  the  lighter  course  the 


CIMOXIC   APPENDICITIS  775 

early  operation  is  not  imperative,  basing  this  view  on  the  mortality 

statistics. 

An  acute  attack  of  simple  appendicitis  running  a  mild  course 
need  not  be  operated  upon  early.  The  modern  experienced  physi- 
cian should  be  capable  of  picturing  to  himself  clearly  the  pathologic 

conditions  present  at  each  stage  of  the  disease  while  utilizing  all 
the  diagnostic  adjuvants  at  his  disposal.  Thus  he  will  not  fail  to 
notice  the  progress  of  the  inflammatory  process.  If  the  diagnostic 
signs  point  to  the  existence  of  a  simple  acute  catarrhal  appendicitis, 
internal  treatment  may  be  adopted.  When  about  to  decide  the 
question  whether  the  early  or  the  late  operation  should  be  selected, 
it  is  of  course  necessary  to  pay  attention  to  the  local  and  particularly 
to  the  general  symptoms.  When  a  practitioner  is  called  to  a  case 
of  appendicitis  he  will  advocate  early  operation  when  the  general 
condition  is  bad.  Grave  disturbances  in  the  general  condition 
always  indicate  high  grades  of  virulency  of  the  infection.  A  case, 
therefore,  cannot  be  considered  a  light  one  when  it  exhibits  great 
prostration,  lassitude,  frequent  emesis,  anxious  facial  expression, 
and  slight  cyanosis.  These  features  of  the  case  are  generally 
accompanied  by  grave  local  symptoms  pointing  to  the  conclusion 
that  the  peritoneal  cavity  has  become  infected,  viz.:  marked 
spontaneous  pains,  increased  sensitiveness  to  pressure  not  only  in 
the  cecal  region  but  also  toward  the  left  and  as  far  as  the  lumbar 
region,  and  the  very  characteristic  board-like  hardness  of  the 
muscles  (defense  musculaire).  These  three  cardinal  symptoms 
necessitate  early  operation,  even  though  there  be  no  severe  general 
symptoms. 

The  inflammatory  exudate  may  be  so  slight  during  the  first 
twenty-four  hours  that  it  is  impossible  to  feel  any  exudative  tumor. 
Early  operation  is  indicated,  however,  when  the  pulse,  the  tempera- 
ture and  the  leukocytosis  show  marked  increase  (temperature 
101°  F.,  pulse  115,  leukocytes  20,000).  Thus  when  the  general 
aspect  of  the  patient  is  unfavorable,  when  the  pulse,  temperature 
and  leukocytosis  are  equally  greatly  raised,  and  when  there  are 
symptoms  of  peritoneal  infection,  it  may  be  taken  for  granted 
that  the  simple  acute  appendicitis  is  passing  on  to  the  more  serious 
form,  and  operation  should  not  be  delayed  one  moment. 

When,  on  the  contrary,  the  general  aspect  of  the  patient  is  satis- 
factory, the  pulse,  temperature  and  leukocytosis  not  high  (tempera- 
ture 99°  F.,  pulse  95,  leukocytes  14,000),  and  when  the  local  symp- 
toms are  moderate,  it  may  be  assumed  that  the  further  development 
of  the  case  will  be  benign,  and  under  such  circumstances  conser- 
vatism and  medicinal  treatment  are  justifiable  and  operation  may 
be  deferred. 

In  any  case  in  which  the  leukocytes  reach  or  exceed  20,000  or 
30,000,  the  patient  should  be  given  over  to  the  surgeon.  The 
characteristic  feature  of  abscess  formation  is  that  from  the  beginning 


776  APPENDICITIS 

— or  at  least  from  the  second  day  on — the  number  of  leukocytes 
rises  rapidly  and  maintains  itself,  with  but  slight  variations,  at 
the  level  reached,  or  goes  even  higher.  After  operation  the  number 
usually  falls  immediately,  although  in  rare  cases  it  may  rise  higher 
than  it  was  before.  In  the  diagnosis  of  abscess  formation,  observa- 
tion of  the  behavior  of  the  leukocytes  far  exceeds  the  temperature 
in  value.  If  there  is  a  sudden  subsidence  of  pain,  and  other  symp- 
toms show  that  the  inflammation  has  not  aborted,  gangrene  may 
be  present  and  operation  should  be  immediately  done.  It  has 
been  observed  that  a  high  absolute  leukocyte  count  (30,000)  with 
a  high  polynuclear  count  (95  per  cent.)  suggests  a  good  prognosis. 
A  low  absolute  count  (7000)  with  a  moderately  high  polynuclear 
indicates  a  bad  prognosis. 

The  internal  medical  treatment  of  simple  acute  appendicitis 
should  be  directed  from  the  very  first  with  a  view  to  the  securing 
of  absolute  rest,  both  of  the  patient  and  of  the  intestinal  tract. 
For  this  purpose  the  patient  is  ordered  to  bed,  which  must  not  be 
left  even  for  micturition  or  defecation.  The  bathing  of  the  patient 
must  also  be  done  in  bed.  An  ice-bag  of  moderate  weight  should 
be  placed  over  the  cecal  region  and  kept  there  day  and  night. 
When  sleep  during  the  night  is  interfered  with  by  the  ice-bag,  it 
may  be  omitted  and  a  Priessnitz  bandage  substituted.  When 
the  pains  are  marked,  the  ice-bag  should  be  suspended  on  a  bed 
hoop  in  such  a  manner  as  just  to  touch  the  cecal  region  while 
hanging.  Opium,  which  formerly  was  regularly  given,  may  usually 
be  omitted  in  light  cases.  It  must  not  be  forgotten  that  opium 
may  mask  the  actual  condition;  it  should  therefore  be  given  only  in 
case  of  very  severe  pain,  and  then  only  in  the  smallest  effective  doses. 

Recently  the  administration  of  purgatives  has  again  been  advo- 
cated, a  practice  which  was  once  considered  strictly  contra-indicated 
in  acute  appendicitis.  Sonnenburg,  who  has  made  a  special  study 
of  appendicitis,  employs  castor  oil  in  the  treatment — on  the  ground 
that  evacuation  of  the  bowel,  and  particularly  of  the  appendix, 
assists  in  removing  stagnating  infectious  materials.  It  is  not  cer- 
tain that  the  peristaltic  intestinal  movements  induced  by  the  castor 
oil  are  capable  of  emptying  the  appendix.  In  simple  catarrhal 
cases  the  evacuation  of  the  bowel  by  castor  oil  is  accompanied 
by  the  disappearance  of  the  sensitiveness  to  pressure  and  by  a 
feeling  of  relief  to  the  patient,  promoting  more  rapid  retrogression 
of  the  disease.  Castor  oil  has  also  the  advantage  of  shedding  light 
on  the  prognosis  and  on  the  course  of  the  disease;  for,  should  it 
prove  ineffectual,  the  attack  not  declining  at  all,  and  no  movement 
of  the  bowel  occurring  after  several  hours,  it  may  be  gathered 
from  these  circumstances  that  an  evacuation  of  the  appendix  has 
not  taken  place,  being  probably  impossible  because  of  the  prevailing 
pathologic  conditions.  Operation  should  then  be  undertaken  at 
once.     The  treatment  with  castor  oil  is  permissible  only  when  the 


CHRONIC  APPENDICITIS  i  -  i 

patient  is  under  constant  surgical  observation  in  a  private  sanitarium 
or  in  a  bospital.     It  is  absolutely  unsuitable  in  the  patient's  home. 

Irrigation  of  the  bowel,  and  enemata,  are  not  i<>  I"-  employed  in 
the  acute  stage,  although  they  are  recommended  by  sonic  authors. 
As  the  patients  partake  of  hut  little  food  during  the  attack,  it 
is  sufficient  to  begin  about  the  sixth  day  to  give  very  small  oil 
enemata,  or  water  injections  with  oil  and  soap,  repeating  daily. 
Glycerin  enemata  are  contra-indicated  because  of  the  fact  that  they 
induce  marked  peristaltic  movements. 

With  respect  to  diet  during  the  acute  attack:  The  patient  should 
take  no  food  during  the  first  twenty-four  hours  or  even  longer. 
The  thirst  should  he  quenched  by  small  pieces  of  cracked  ice  and 
by  the  moistening  of  the  mouth  with  water.  During  the  next  few 
days  iced  milk  should  be  given  in  sips,  and  then  small  amounts  of 
gruel  and  some  beef  tea.  This,  after  the  attack  passes  off,  is  to 
be  followed  by  beef  tea  with  egg,  milk,  soup,  and  tea;  and  later, 
gradually,  finely  chopped  tender  meat,  mashed  potatoes,  vegetables 
and  apple  sauce  may  be  allowed.  After  the  first  natural  bowel 
movement  the  diet  may  become  somewhat  more  free.  Great  care 
should  be  exercised  with  the  diet  for  a  considerable  length  of  time 
after  the  attack;  all  food  should  be  cut  up  minutely,  and  all  strong, 
irritating  articles  of  food  should  be  avoided.  In  the  event  of 
constipation  supervening,  it  should  be  counteracted  by  a  chemically 
purgative  diet.  (See  Chapter  VII  on  Diet.)  Fatiguing  bodily 
activity,  exercise,  golf,  sports  and  abdominal  massage  are  to  be 
forbidden  for  a  long  time  and  in  some  cases  for  years. 

After  the  acute  attack,  it  is  the  best  practice  to  remove  the 
appendix  at  once,  or,  if  this  is  impracticable,  to  allow  an  interval  of 
about  ten  days  to  elapse.  The  operation  should  take  place  when 
all  the  inflammatory  symptoms  have  subsided  and  when  all  adhe- 
sions which  may  have  formed  have  become  firm.  At  this  time  it  is 
neither  difficult  nor  serious;  the  wound  can  be  closed  and  allowed 
to  heal  by  first  intention,  and  the  mortality  in  cases  of  simple 
appendicitis  does  not  exceed  0.6  to  0.9  per  cent.  It  must  be  in- 
sisted upon  that  appendectomy  is  the  only  certain  prophylaxis 
which  will  positively  exclude  recurrences.  Internal  remedies  are 
absolutely  useless  in  this  respect. 

There  is  a  large  class  of  cases  which  must  be  treated  medically, 
because  for  one  reason  or  another  it  is  impracticable  to  operate 
early.  The  patient  may  be  in  the  country,  and  operation  may  be 
inadvisable  because  of  old  age  or  the  presence  of  lung  or  heart 
disease  or  diabetes.  There  are  also  instances  in  which  the  patient 
refuses  to  permit  an  operation,  and  those  obscure  cases  in  which 
it  cannot  be  decided  positively  whether  the  disease  is  appendicitis, 
cholelithiasis,  pyosalpinx,  typhoid  fever,  or  hysteria.  In  such 
cases  the  usual  treatment,  as  described  above,  is  to  be  followed 
out.     When  more  serious  symptoms  supervene,  opium  should  be 


778  APPENDICITIS 

given,  because  by  inhibiting  peristalsis  it  prevents  traction  of  the 
intestine  upon  the  inflamed  peritoneum,  thus  counteracting  any 
tendency  toward  the  development  of  peritoneal  infection.  Local 
applications  of  ice  are  to  be  persistently  maintained,  but  purgatives 
positively  prohibited.  Absolute  bodily  rest  is  to  be  insisted  upon, 
that  perforation  from  abscesses  possibly  present  may  be  prevented. 
The  diet  should  be  as  already  described. 

Under  the  conservative  treatment  severe  cases  sometimes  recover, 
but,  generally  speaking,  it  is  impossible  to  prevent  the  develop- 
ment of  destructive  appendicitis  by  internal  medication.  In  case  of 
recovery,  subsequent  operation  must  be  performed.  _  Without  such 
operation  these  cases  of  appendiceal  abscess  show  a  high  mortality, 
as  against  0.6  to  0.9  per  cent,  after  early  operation. 

When  operation  is  delayed  until  the  third  day,  the  conditions  are, 
as  a  rule,  much  less  favorable  than  those  of  early  operation.  It 
is  very  rare  indeed  that  the  process  at  that  time  continues  to  be  as 
suitable  for  surgical  treatment  as  on  the  first  two  days;  moreover, 
these  cases  present  a  bad  outlook  either  with  or  without  an  opera- 
tion. When  encapsulation  has  not  taken  place  the  process  usually 
becomes  progressive.  If  a  circumscribed  abscess  has  been  formed, 
there  is  no  immediate  danger  of  death;  the  advice  of  the  surgeon, 
therefore,  is  not  to  interfere  with  this  process  of  encapsulation  by 
operative  procedure;  operation,  however,  offers  relatively  good 
chances  if  the  abscess  can  be  evacuated  without  opening  the  peri- 
toneal cavity.  The  intestine  may  perforate  spontaneously  by 
rupture  of  the  abscess  into  it,  and  by  this  means  a  cure  be  effected 
by  nature. 

If  signs  of  peritonitis  develop,  continuous  saline  infusions  into 
the  colon  by  the  Murphy  drip  should  be  given.  This  method 
of  administering  saline  solution  is  claimed  to  be  of  such  great 
value  in  diminishing  toxemia  and  in  saving  life  that  a  detailed 
description  of  it  is  given  on  page  239.  Under  this  treatment  the 
blood-pressure  is  restored  to  normal,  thirst  is  quenched,  and  septic 
products  are  more  readily  excreted. 

Morphin  or  opium  should  be  administered  in  sufficient  quantity 
to  stop  peristalsis.  Stockton1  does  not  advocate  the  opium  treat- 
ment to  the  displacement  of  surgery  in  general  septic  peritonitis,  but 
believes,  with  Alonzo  Clark,  that  its  greatest  field  of  usefulness  is 
in  those  comparatively  mild  cases  in  which  the  inflammation  has 
not  yet  become  general.  Clark  taught  that  as  soon  as  the  diagnosis 
was  made  the  largest  safe  dose  of  opium  should  be  administered. 
He  aimed  to  use  very  large  doses,  with  long  intervals  between, 
yet  never  to  allow  the  patient  to  emerge  from  the  sedative  effects 
of  the  drug.  In  general  peritonitis  the  amount  of  opium  and  mor- 
phin that  can  be  taken  safely  is  remarkable.     The  aim  of  the  treat- 

1  Charles  G.  Stockton,  The  Opium  Treatment  of  Peritonitis,  Buffalo  Medical 
Journal,  February,   1908,  p.  373. 


I  HRONIC  APPENDICITIS  77!) 

incut  is  tn  keep  the  patient  a>  quiet  a^  possible  and  yel  within  the 
borderland  of  safety.  To  one  experienced  with  the  drug  in  this 
disease,  there  is  little  danger  of  overuse.  As  the  inflammation 
subsides,  the  tolerance  for  opium  decreases  and  the  dosage  is 
lessened,  and  very  soon  it  is  unnecessary  to  administer  any  anodyne 
whatever. 

Stockton  teaches  that  the  proper  treatment  of  oncoming  septic 
peritonitis  is  immediate  operation,  hut  that  when  the  operation 
is  delayed  and  the  inflammation  is  becoming  general  it  is  advisable 
to  use  the  full  opium  treatment  until  such  time  as  the  suppuration 
is  localized  and  drainage  effected  without  molesting  the  greater 
part  of  the  abdominal  cavity. 

Treatment  of  Chronic  Appendicitis. — Removal  of  the  appendix 
after  an  acute  attack  will,  of  course,  prevent  recurrence  and  the 
more  insidious  advances  of  chronic  appendicitis.  Xo  internal 
medicine  otters  such  security.  There  may  be  small  ulcers  or 
abscesses  in  the  appendix  in  apparently  cured  cases,  which  at  any 
moment  may  excite  an  acute  attack.  When  operation  is  not 
performed,  the  patients  are  compelled  to  alter  their  entire  mode 
of  living,  for  the  sake  of  prophylaxis,  into  a  regimen  of  rest  and 
observance  of  the  strictest  dietary  precautions.  The  great  majority 
of  people  are  incapable  of  persevering  and  are  unwilling  to  submit 
to  such  restrictions;  many  of  them,  of  their  own  initiative,  demand 
an  operation.  The  chances  without  operation  are  even  worse  in 
the  case  of  children,  because  of  their  natural  restlessness. 

When  an  operation  is  refused,  it  is  necessary  to  demand  of  the 
patient  that  he  avoid  bodily  exertions,  give  up  gymnastics  and 
hard  bodily  labor,  take  most  particular  pains  not  to  commit  any 
errors  in  diet,  and  avoid  any  external  irritation  in  the  region  of 
the  cecum.  Particular  attention  must  be  given  to  regularity  of  the 
alvine  discharges. 

The  food  should  be  carefully  subdivided  and  heavy  residual 
matter  avoided.  When  constipation  is  present  the  diet  should  be 
of  such  a  nature  as  to  act  chemically  as  an  evacuant  (see  page  1S5). 
Cascara-agar  should  be  employed  as  an  adjunct  to  the  diet.  Rectal 
injections  of  oil  may  also  be  employed  (see  page  223).  Liquid 
petrolatum  (see  page  664)  is  a  soothing  lubricant  to  the  mucous 
membrane  and  prevents  irritation  by  scybala;  it  is  antiseptic, 
emollient  and  laxative,  and  can  be  given  in  tablespoonful  doses 
three  or  more  times  a  day.  Menthol  or  thymol  may  be  added  to 
the  dose  when  desired. 

In  these  non-operative  cases,  systematic  drinking  cures  may 
be  undertaken  at  Saratoga,  Carlsbad,  Marienbad,  Kissingen,  or 
Wiesbaden.  Favorable  effects  are  also  frequently  obtained  from 
mud  baths  (Mudlavia,  Indiana),  also  from  local  applications  of 
mud.  The  absorption  of  exudates  of  long  standing  is  often  pro- 
moted by  means  of  these  baths  and  applications.     The  use  of  the 


780  APPENDICITIS 

hot-water  bag,  hot-water  stupes,  oil  and  turpentine,  linseed  or 
mashed-potato  poultices,  Priessnitz  bandages,  and  thermophores 
has  the  same  purpose  and  similar  effects.  Massage  and  purgatives 
are  contra-indicated. 

WheD  these  measures  are  observed  for  a  long  time  and  with 
strict  regularity  it  is  occasionally  possible  to  relieve  the  condition 
and  remove  the  danger  of  relapse,  although  this  result  cannot  be 
assured.  Such  a  very  guarded  method  of  living  cannot  be  main- 
tained by  all  {e.  g.,  workingmen),  and  it  may  become  necessary 
after  all  to  operate. 

Bacterial  vaccines  have  been  used  in  the  treatment  of  appendicitis 
with  occasional  success.  Colon  bacillus,  streptococcus,  staphylo- 
coccus, pneumococcus  and  pyocyaneus  infections  are  the  bacterial 
causes  of  peritonitis  in  appendicitis,  and  immunization  against 
these  organisms  in  appendicitis  is  unquestionably  of  benefit  whether 
the  case  is  to  have  an  operation  or  not.  A  mixed  polyvalent 
stock  vaccine,  consisting  of  the  above-named  organisms,  should  be 
given.  Specific  agents  which  have  the  power  to  neutralize  toxic 
microbic  products,  destroy  the  microbes,  or  dissolve  foreign  protein 
substances,  are  called  antibodies.  Substances  which,  introduced 
into  the  blood,  lead  to  the  formation  of  antibodies,  are  antigens. 
The  modified  bacterial  derivatives  prepared  according  to  the 
process  of  Schafer  consist  mainly  of  antigens.  The  trade  name 
"phylacogen"  has  been  given  to  these  products.  Phylacogens  are 
sterile  aqueous  solutions  of  metabolic  substances,  or  derivatives, 
generated  by  bacteria  grown  in  artificial  media.  Pathogenic  bac- 
teria, such  as  Staphylococcus  albus  and  aureus,  Bacillus  pyocya- 
neus, Diplococcus  pneumoniae,  Bacillus  coli  communis,  Strepto- 
coccus hemolyticus  and  viridans,  Micrococcus  catarrhalis,  etc.,  are 
employed  in  the  production  of  these  so-called  phylacogens,  or 
"phylaxin  developers."  The  mixed-infection  phylacogen  has  been 
used  with  good  effect  in  some  cases  of  appendicitis. 


(HATTER    L. 

NERVOUS  DISEASES  OF  THE  INTESTINE. 

Enterosfasm;  Tormina  Intestinorum  Nervosa;  Paresis; 
Enteralgia. 

The  coordination  of  vagus  and  sympathetic  nervous  impulses 
regulates  the  digestive  functions.  The  stomach  and  intestine 
possess  ganglionic  cells,  situated  in  the  muscles  and  glands,  which 
have  the  power  of  allowing  the  organs  to  function  in  an  inde- 
pendent manner.  There  are  fibers  from  the  medulla  which  inter- 
mingle with  the  sympathetic  and  ganglionic  cells  so  that  these  organs 
are  also  under  the  influence  of  the  central  nervous  system.  In 
the  normal  condition  the  innervation  induces  a  continuous  tonus 
which  oscillates  between  certain  limits.  The  fibers  of  the  sympa- 
thetic, or  the  splanchnics,  check  or  retard  the  activity  of  the  diges- 
tive organs,  especially  with  regard  to  secretions  and  motility. 
The  fibers  of  the  vagus  send  impulses  inducing  contraction  and 
tonicity  of  the  muscles  of  the  digestive  organs.  Every  increase 
of  irritation  of  the  vagus  increases  this  effect  on  the  activity  of  the 
muscles  of  the  intestinal  canal.  Excessive  irritation,  or  vagotonia, 
brings  about  an  increase  in  the  secretion  of  juices,  and  spastic 
contractions  of  different  sections  of  the  intestine  (see  page  388). 

ENTEROSPASM. 

Symptoms. — The  symptoms  of  enterospasm  consist  of  painful 
contractions  of  the  intestine,  followed  by  marked  intestinal  peri- 
stalsis accompanied  by  borborygmi.  When  a  wave  of  peristalsis 
passes  down  on  a  segment  of  intestine  that  is  already  spastically 
contracted,  the  result  is  cramp  or  colic.  During  the  height  of  the 
painful  seizure  the  necessity  for  defecation  becomes  urgent,  and  the 
discharges,  expelled  with  pain  and  tenesmus,  consist  of  small  fecal 
fragments  in  the  form  of  narrow  cylinders  or  balls.  The  attacks 
occur  spasmodically,  and  may  occlude  the  part  of  the  intestine 
involved.  Mental  and  nervous  conditions  may  give  rise  to  these 
attacks.  The  diagnosis  is  not  difficult,  in  view  of  this  typical 
course  and  the  absence  of  any  organic  disease. 

Treatment. — The  therapeutic  measures  must  be  particularly 
directed  toward  the  general  nervous  system.  Physical  and  hydri- 
atic  procedures  are  valuable.  A  hot  bath  is  grateful  and  gives 
quick  relief.     Galvanism  applied  to  the  intestine,  with  one  flat 


782  NERVOUS  DISEASES  OF   THE  INTESTINE 

electrode  over  the  abdomen  and  the  other  in  the  rectum,  is  useful. 
Both  prophylactically  and  during  the  attack,  warm  applications 
to  the  abdomen  should  be  made.  Carminative  teas  will  frequently 
relieve  the  spasm  (see  page  658) .  Anodynes,  such  as  opium,  bella- 
donna, morphin,  hyoscyamus,  and  the  bromids,  are  to  be  employed. 
The  nitrites,  by  inhibiting  peristalsis,  relieve  the  cramp  or  colic. 
Suppositories  of  the  anodynes  frequently  give  quick  relief.  Papav- 
erin  and  benzyl  benzoate  are  also  efficacious  (see  page  276).  Chloral 
hydrate  dissolved  in  warm  water  can  be  introduced  into  the  rectum. 
Hot  oil  enemata  are  valuable.  Chronic  constipation  should  be 
appropriately  treated  (see  page  659) . 

TORMINA  INTESTINORUM  NERVOSA. 

Peristaltic  restlessness  was  first  described  by  Kussmaul.  It 
consists  in  the  development  of  intense  peristaltic  motions,  visible 
through  the  abdominal  walls.  It  occurs  in  nervous  patients, 
especially  under  the  influence  of  exciting  emotions.  During  the 
attack  the  patients  experience  a  feeling  of  distention  and  con- 
traction in  the  abdomen,  associated  with  pain  and  loud  intestinal 
noises.  These  symptoms  are  not  dependent  on  the  ingestion  of 
food.  The  active  peristaltic  movements  are  quite  apparent  on 
inspection  of  the  abdomen,  especially  when  the  abdominal  walls 
are  thin.  The  small  intestine  is  usually  the  part  most  prominently 
involved,  but  the  colon  may  participate.  The  attacks  often  per- 
sist for  a  long  time,  and  may  vary  considerably  in  their  intensity. 
When  making  a  diagnosis  the  possibility  of  stricture  of  the  intestine 
must  be  borne  in  mind  (see  page  755). 

Treatment. — The  treatment  is  directed  chiefly  toward  the  strength- 
ening of  the  entire  nervous  system.  All  the  adjuvants  of  general 
physical  therapeutics  are  utilized  for  this  purpose.  Change  of 
climate  and  sojourn  in  mountainous  regions  are  occasionally  quite 
beneficial.  The  application  of  the  faradic  current  to  the  abdomen, 
stomach  and  rectum  is  sometimes  successful.  Rest  cures  and 
hyperalimentation  (see  page  569)  are  frequently  of  great  value.  The 
bromids,  opium,  belladonna,  codein,  chloral  hydrate  and  strychnin 
may  be  given. 

Gm.  or  Cc. 
1^ — Tincturae  belladonnas, 

Tincturse  nucis  vomicae      .      .      .   aa      10 10  oiiss 

Misce. 
Sig. — Fifteen  drops  three  or  four  times  daily. 

PARESIS  OF  THE  INTESTINE. 

Paresis  of  the  bowel  is  a  functional  relaxation  of  the  intestinal 
muscle  fibers,  and  is  found  in  chronic  constipation  and  in  various 
organic  intestinal  affections;  also  as  a  result  of  the  continued  use  of 
opium,  morphin,  or  belladonna;  and  from  neuroses,  psychoses,  and 


ENTERALGIA  783 

sudden  mental  shocks,  traumatisms,  and  depressing  influences,  or 
the  use  of  large  and  long  continued  enemata.     ( longenital  intestinal 

paresis  is  also  occasionally  found. 

In  studying  the  conditions  attending  operation  as  possible  causes 
of  postoperative  paralysis  of  the  alimentary  canal,  Cannon  and 
Murphy  made  observations  on  animals  and  found  thai  etherization 
continued  from  hall  an  hour  to  an  hour  and  a  half  did  not  delay 
to  any  marked  degree  the  discharge  of  food  from  the  stomach; 
neither  did  exposure  to  the  air  or  unusual  cooling  of  the  gut  cause 
any  noteworthy  delay;  hut  by  far  the  most  striking  effects  were 
seen  after  handling  the  viscera.  Even  with  most  gentle  hand- 
ling, within  the  peritoneal  cavity  or  under  warm  salt  solution, 
no  gastric  peristalsis  was  seen  and  no  food  left  the  stomach  for 
three  hours.  Fingering  gently  in  the  air  caused  still  greater  retarda- 
tion of  the  movement  of  the  food,  and  with  rough  handling  in  air 
no  food  passed  from  the  stomach  for  four  hours  and  then  it  emerged 
very  slowly  and  was  moved  onward  with  every  evidence  of  extreme 
sluggishness  of  the  intestine. 

Insufficiency  of  the  ileocecal  valve  is  a  peculiar  variety  of  intes- 
tinal paresis.  A  considerable  degree  of  insufficiency  of  this  valve 
may  be  induced  by  neighboring  inflammatory  processes,  mani- 
festing itself  by  meteorism  of  the  small  intestine,  constipation, 
flatulence,  and  nervous  disturbances.  The  diagnosis  is  aided  mainly 
by  the  associated  constipation  and  roentgenologic  examination  (see 
page  561  and  Plate  XIX,  Fig.  2). 

Treatment. — The  treatment  is  directed  toward  the  constipation 
(see  Chapter  XXXVII).  Faradization  and  massage  of  the  large 
intestine  is  recommended  in  insufficiency  of  the  ileocecal  valve. 

ENTERALGIA. 

(Enteralgia  Nervosa — Intestinal  Colic — Colica  Flatulenta.) 

This  affection  manifests  itself  by  the  periodic  occurrence  of 
painful  sensations  within  the  abdomen  without  an  anatomic  lesion 
of  the  gut  or  the  nerves.  Kast  and  Meltzer  have  found  that, 
contrary  to  the  accepted  opinion,  the  normal  gastro-intestinal 
tract  possesses  a  sense  of  pain — which  is  considerably  augmented 
when  the  parts  are  inflamed. 

The  seat  of  the  enteralgia  is  the  large  nervous  plexuses,  the 
mesenteric,  hypogastric,  and  celiac.  The  causes  are  gout,  malaria, 
lead  poisoning,  tabes,  hysteria,  and  neurasthenia.  The  pains 
are  of  a  paroxysmal  nature,  are  located  in  the  gastric  region,  and 
may  attain  great  severity.  The  gastric  crises  (crises  enieriques)  of 
tabetic  patients  are  especially  characteristic  (see  page  412).  Objec- 
tively nothing  can  be  elicited.  The  diagnosis  is  quite  difficult  in 
those  cases  in  which  the  above  causes  cannot  be  found.  When 
making  a  differential  diagnosis,  the  colics  due  to  renal  calculi  or 


784  NERVOUS  DISEASES  OF   THE  INTESTINE 

gallstones  are  to  be  borne  in  mind.  Hernia  of  the  linea  alba  must 
not  be  overlooked. 

Treatment. — The  treatment  should  be  directed  toward  the  original 
cause.  Symptomatic  indications  are  offered  for  the  application  of 
heat,  hot  enemata,  galvanization,  and  anodynes. 

Chloral  hydrate  in  combination  with  morphin  and  belladonna 
is  useful : 

Gm.  or  Cc. 
fy — Morphini  hydrochloridi      ....  06  gr.  j 

Chloralis  hydratis 12  0  o  ii j 

Syrupi  aurantii, 

Aquae aa     30  0  5j 

Misce. 

Sig. — One  or  two  teaspoonfuls  every  hour  during  the  attack. 

For  the  relief  of  severe  pain: 

Gm.  or  Cc. 

^ — Codeinse  phosphatis 1J0  gr.  xv 

Acidi  acetylsalicylici 4|0  5j 

Misce  et  ft.  caps.  no.  xvi. 

Sig. — One  every  hour  until  better. 

The  treatment  is  similar  to  that  of  gastralgia  (see  Chapter  XVIII). 


CHAPTER  LI. 

PEBISIGMOIDITTS— DIVERTICULITIS  —  PERIDIVERTIC- 

l  LITIS— SIGMOIDITIS;  IDIOPATHIC  DILATATION 

OF  THE  COLON. 

PERISIGMOIDITIS  AND  DIVERTICULITIS. 

Acute  Perisigmoiditis. — Acute  perisigmoiditis  is  a  disease  that 
runs  a  course  very  similar  to  that  of  acute  appendicitis.  It  is  at 
present  comparatively  little  known.  An  endosigmoidal  and  an 
exosigmoidal  origin  of  the  disease  are  recognized.  The  affection 
commences  endosigmoidallv  by  direct  continuation  of  inflammatory 
processes  from  the  descending  colon  and  the  upper  portion  of  the 
rectum  (severe  catarrhs,  fecal  stagnation,  stercoral  ulcers,  colitis 
ulcerosa,  diverticulitis)  to  the  peritoneal  coating  of  the  intestine  and 
the  adjacent  peritoneum.  A  perisigmoidal  exudate,  either  serous  or 
purulent,  may  develop.     These  cases  are  not  very  common. 

Stagnation  of  the  feces  occurs  mostly  in  the  lower  portion  of  the 
descending  colon  and  in  the  sigmoid  flexure,  the  peculiar  anatomy 
of  which  virtually  invites  the  retention  of  fecal  material.  Inflam- 
matory processes  of  the  sigmoidal  mucosa  may  thus  be  set  up 
readily,  to  some  extent  by  mechanical  injury  from  the  accumulated 
excrementitious  substances,  and  to  some  extent  by  chemical  irrita- 
tion from  the  products  of  secondary  decomposition  evolved  from  the 
impacted  feces.  Intestinal  spasm,  atony,  or  paresis,  by  occasion- 
ing constipation,  may  be  the  more  remote  cause  of  chronic  inflam- 
matory processes  of  the  sigmoid  flexure.  The  great  majority  of 
all  intestinal  affections  which  are  due  to  insufficient  or  perverse 
innervation  arise  in  the  sigmoid.  Initial  intestinal  spasm  is  almost 
invariably  confined  to  the  sigmoid;  intestinal  atony  or  paresis,  as 
a  rule,  starts  in  the  sigmoid;  70  per  cent,  of  all  cases  of  volvulus 
—due  primarily  in  almost  every  instance  to  fecal  impaction  and 
induced  forced  peristalsis,  that  is,  perverse  innervation — occur 
in  the  sigmoid  flexure.  Chronic  sigmoiditis  may  be  associated 
with  numerous  concomitants  and  complications.  Its  occurrence, 
in  fact,  favors  the  development  of  other,  especially  functional, 
disturbances  of  the  alimentary  canal.  Functional  disorders  of  the 
cecum,  for  instance,  are  often  due  to  a  chronic  pathologic  condition 
of  the  sigmoid.  The  synchronous  occurrence  of  cecal  derangement 
and  the  syndrome  of  chronic  sigmoiditis  often  presents  the  clinical 
picture  of  chronic  appendicitis.  Again,  we  know  that  in  the  etiology 
of  appendicitis  itself,  chronic  constipation  (and  consequently  sig- 
50 


786         PERISIGMOIDITIS— DILATATION  OF  THE  COLON 

moidal  disease)  plays  an  important  role.  Furthermore,  perisig- 
moiditis may  be  due  to  the  same  cause  which  gives  rise  to  endo- 
sigmoiditis,  or  it  may  be  the  direct  consequence  of  the  latter,  and 
inflammatory  processes  in  other  parts  of  the  peritoneum  may  be 
engendered  by  chronic  sigmoiditis  or  its  most  frequent  immediate 
precursor,  constipation. 

Perisigmoiditis  of  exogenous  origin  occurs  quite  often.  Inflam- 
mation, exudation,  and  the  formation  of  an  abscess  may  occur  in 
the  course  of  diseases  of  neighboring  organs,  as  the  female  genitals, 
the  kidneys,  or  the  ureters,  or  in  a  case  of  psoas  abscess.  It  must 
also  be  remembered  that  an  exudate  from  an  acute  appendicitis 
may  become  localized  perisigmoidally. 

Diverticula  may  occur  in  any  part  of  the  small  or  large  bowel. 
Those  in  the  former  are  as  a  rule  congenital,  and  those  in  the  descend- 
ing and  pelvic  colon  usually  acquired.  Diverticulitis  is  due  to  infec- 
tion in  the  walls  of  one  or  more  diverticula ;  these  walls  usually  show 
evidence  of  chronic  inflammation  in  the  mucous  and  submucous 
coats,  the  latter  abounding  in  fat.  The  diverticulum  seldom  shows 
longitudinal  or  circular  muscle  fibers,  but  frequently  contains  hard, 
black  fecal  concretions.  Hyperplasia  of  all  adjacent  glands  occurs, 
and  a  large  inflammatory  mass  is  caused  by  outward  bacterial 
invasion.  Fecal  concretions  frequently  cause  chronic  irritation, 
and  produce  a  secondary  peridiverticulitis  which  may  eventuate  in 
abscess  formation. 

Diverticulitis.  —  Diverticula  of  the  small  intestine  are  rare, 
although  several  cases  have  recently  been  reported  recognized  by 
the  Roentgen  ray.  They  are  more  often  found  in  the  duodenum 
than  in  the  jejunum  or  ileum. 

Diverticulitis  of  the  sigmoid  may  be  either  congenital  or  acquired. 
These  small  hernial  protrusions  of  the  coats  of  the  bowel  may  occur 
anywhere  in  the  large  intestine,  but  are  most  common  in  the  sig- 
moid, ending  abruptly  at  the  rectum.  Unless  they  undergo  secon- 
dary changes  they  do  not  give  rise  to  any  symptoms  (Eisendrath) . 
Multiple  diverticula  always  occur  in  large  numbers;  in  some  in- 
stances several  hundred  of  them  are  distributed  over  the  entire 
large  intestine,  notably  in  the  sigmoid  flexure  and  the  rectum. 
Diverticula  are  most  apt  to  occur  in  two  rows,  at  either  side  of  the 
gut.  They  may,  however,  develop  at  the  mesenteric  attachment 
and  appear  between  the  layers  of  the  mesentery.  In  some  cases 
they  are  simply  protrusions  of  the  mucous  membrane  into  the 
appendices  epiploicse,  while  in  others  they  form  definite  pouches, 
either  oval  or  flask-shaped. 

The  sigmoid  loop  in  which  the  diverticula  are  found  is  frequently 
filled  with  fat,  and  Telling1  has  demonstrated  that  this  fat  entirely 
conceals  the  hernial   protrusions,   more   especially  as   these   are 

1  W.  H.  M.  Telling,  The  Clinical  Aspects  and  Importance  of  Sigmoid  Diver- 
ticula, The  Proctologist,  March,  1911,  p.  14. 


PERISIGMOIDITIS  AND  DIVERTICULITIS 


■s7 


mostly  into  the  epiploic  appendages.  Even  when  the  fat  is  present 
only  in  moderate  amount  the  condition  is  easily  overlooked  by 
any  one  not  familiar  with  the  characteristic  appearances.  Fig. 
Ill)  illustrates  a  well  marked  case  with  the  fat  removed  from  the 
outer  aspect  of  the  bowel.  Fig.  Ill  illustrates  the  inner  surface 
of  the  same  specimen.  Fig.  112  illustrates  a  ease  in  which  the  fat 
has  been   dissected   from  one  half  of  the  bowel,  and   shows  the 


ETHEL  tf   ^SiGHT 

'9°9 


Fig.  110. — Diverticula  of  the  sig- 
moid flexure.  The  fat  has  been  dis- 
sected from  the  outer  aspect  of  the 
bowel.  The  pouches  are  for  the  most 
part  into  the  appendices  epiploicse.  a, 
one  of  the  sacs  open.     (Telling.) 


Fig.  111. — Diverticula  of  the  sigmoid 
flexure.  Inner  surface  of  the  bowel. 
b,  a  concretion  at  the  orifice  of  one  of 
the  diverticula;  c,  lipped  orifice.  (Tel- 
ling.) 


pouches  which  entered  the  appendices  epiploicae.  The  diverticula 
usually  contain  fecal  matter  or  concretions  of  varying  degrees  of 
hardness.  Serious  results  may  follow  the  thinning  of  the  diver- 
ticulum wall,  the  perforating  action  of  the  retained  concretions, 
and  the  presence  of  microorganisms  and  their  toxins.  The  most 
frequent  pathologic  effect  of  these  diverticula  is  a  chronic  prolifera- 
tive inflammation  and  the  resultant  perisigmoiditis.     The  change 


788 


PERISIGMOIDITIS— DILATATION  OF  THE  COLON 


that  takes  place  is  of  the  proliferative  type,  and  a  mistaken  diagnosis 
of  carcinoma  may  be  easily  made  (Fig.  113).  This  proliferative 
inflammation  involves  the  whole  circumference  of  the  bowel  for  a 
varying  distance  (two  to  eight  inches  as  a  rule),  and,  besides  giving 
rise  to  the  formation  of  a  definite  tumor,  the  inevitable  contraction 
of  the  new-formed  fibrous  tissue  leads  to  a  slow  stenosis  of  the  bowel. 


£*? 

Fig.  112. — -Diverticula  of  the  sigmoid  flexure.  The  fat  has  been  dissected  from 
one  side  of  the  bowel,  showing  the  pouches  which  entered  the  appendices  epiploicse. 
a,  a  single  pouch  dissected  out  to  show  how  they  are  buried  in  fat  and  liable  to  pass 
unrecognized  unless  especially  sought  for;  b,  longitudinal  muscular  band;  c,  a  con- 
cretion.    (Telling.) 

One  of  the  most  important  factors  in  the  production  of  diverticu- 
litis is  muscular  weakness  incident  to  old  age,  and  the  presence  of 
considerable  fat  in  the  intestinal  wall  which  favors  a  pushing-out 
of  the  mucosa.  The  most  frequent  secondary  pathologic  changes 
are :  (a)  infection  of  the  general  peritoneal  cavity  without  perfora- 
tion; (b)  acute  or  gangrenous  inflammation  resembling  the  same 
pathologic  form  of  appendicitis ;  (c)  acute  perforation  or  formation 
of  an  abscess,  or  general  peritonitis.  These  pathologic  forms 
greatly  resemble  corresponding  types  of  appendicitis. 


PERISIGMOIDITIS  AND  DIVERTICl  LITIS 


789 


Multiple  diverticula  in  a  non-inflammatory  condition  arc  only 
discovered  at  autopsy,  as  they  present  no  clinical  manifestations. 

But  the  feces  contained  in  them  may  cause  inflammation,  necrosis, 
ulceration,  and  perforation.  The  latter  is  usually  of  small  dimen- 
sions and  becomes  encapsuled  or  adherent.  It  may,  however,  lead 
to  slowly  progressing  ulceration  and  diffuse  peritonitis.  Such  a 
condition  may  he  mistaken  for  appendicitis. 

Clinically  a  distinction  is  made  between  acute  simple  and  acute 
ulcerative  perisigmoiditis.  In  the  former  group  are  classed  those 
cases  in  which  there  may  be  found,  aside  from  the  slight  general 
symptoms  and  sensitiveness  to  pressure,  some  resistance  in  the 
region  of  the  sigmoid  flexure,  but  the  contour  of  the  bowel  is  not 
concealed;  at  the  same  time  there  are  constipation  and  slight 
fever.  With  proper  treatment  these  phenomena  gradually  dis- 
appear  within  five  to  eight  days.     The  cases  of  ulcerative  peri- 


*# 


Fig.  113. — Perisigmoiditis  with  great  thickening  of  the  gut  wall,  causing  stenosis 
and  simulating  carcinoma,     a,  thickening  due  to  fibrosis.     (Telling.) 

sigmoiditis  are  those  in  which  the  primary  symptoms  become 
worse,  with  high  fever  and  grave  general  conditions;  a  large  exudate 
or  abscess  may  develop  in  the  region  of  the  flexure.  At  this  period 
large  abscesses  may  undergo  absorption.  Occasionally,  however, 
serious  complications  arise,  such  as  perforation  and  peritonitis. 

Symptoms. — The  clinical  symptoms,  sudden  onset,  pains,  vomiting 
and  fever,  frequently  correspond  to  those  of  acute  appendicitis 
with  symptoms  on  the  left  side,  and  for  this  reason  it  is  often 
difficult  to  establish  the  correct  diagnosis.  In  cases  of  divertic- 
ulitis we  may  have  gangrene,  peritonitis,  and  death.  These  diver- 
ticula are  a  series  of  appendix-like  structures  and  are  subject  to 
the  same  pathologic  changes  as  the  vermiform  appendix.  The 
appendix  itself  is  only  a  blind  diverticulum  of  the  intestine.  The 
symptoms  suggesting  an  endogenous  perisigmoiditis  are,  a  his- 
tory of  coprostases,  diarrheas,  and  the  finding  of  blood  and 
pus  in  the  stools.    Rectal  and  vaginal  examinations  are  never  to 


790        PERISIGMOIDITIS— DILATATION  OF  THE  COLON 

be  overlooked.  The  sigmoidoscope,  which  may  frequently  clear 
up  the  diagnosis  of  this  condition,  is  not  to  be  used  during  the 
acute  stage  of  the  disease.  In  all  cases  of  diverticulitis  the 
diagnosis  can  be  easily  made  by  the  use  of  the  Roentgen  ray  and 
barium  sulphate  or  bismuth  subcarbonate  (see  page  148  and  Plate 
XXII,  Fig.  1). 

Treatment. — Prophylactically,  careful  attention  should  be  directed 
to  coprostasis  in  the  region  of  the  sigmoid  flexure,  to  chronic  con- 
stipation, and  to  chronic  ulcerative  colitis,  in  order  to  prevent 
the  development  of  a  perisigmoidal  affection.  A  well  developed 
case  is  treated  similarly  to  one  of  appendicitis — absolute  rest  in 
bed,  ice  applied  locally,  abstinence  from  food,  or  slight  quantities 
of  fluid  or  semisolid  nutriment,  and  opium  or  morphin.  In  very 
light  cases,  in  which  fecal  retention  can  be  demonstrated,  very 
cautious  attempts  may  be  made  to  evacuate  the  bowel  by  means  of 
rectal  irrigations.  The  greater  percentage  of  cases  of  endogenous 
perisigmoiditis  go  through  to  recovery  without  surgical  intervention, 
a  measure  which  is  undertaken  more  frequently  in  exogenous  peri- 
sigmoiditis. Generally  speaking,  it  is  permissible  to  wait  longer 
in  perisigmoiditis  before  operating  than  in  appendicitis. 

Many  patients  suffering  from  diverticulitis  have  been  greatly 
relieved  after  taking  the  barium  or  bismuth  test  meal.  Repeated 
Roentgen-ray  examination  proves  that  these  metals  really  have  an 
influence  on  the  multiple  diverticula.  It  has  thus  been  found 
that  barium  sulphate  or  bismuth  subcarbonate  in  60-Gm.  (2-ounce) 
doses  is  very  valuable  in  the  treatment  of  cases  of  diverticulitis. 
This  dose  should  be  taken  in  the  morning  on  an  empty  stomach 
once  a  week  for  three  or  four  weeks.  These  patients  do  better 
without  cathartics. 

Chronic  Perisigmoiditis. — After  recovery  from  an  acute  peri- 
sigmoiditis, there  may  result  cicatricial  processes  of  contraction  and 
adhesions,  interfering  with  the  passage  of  feces  into  the  sigmoid 
flexure.  Under  such  circumstances  it  may  become  necessary  to 
resort  to  surgical  intervention. 

IDIOPATHIC  DILATATION  OF  THE  COLON— HIRSCHSPRUNG'S 

DISEASE— CONGENITAL  MEGACOLON— CONGENITAL 

DILATATION  OF  THE  COLON. 

The  term  "idiopathic  dilatation  of  the  colon,"  or,  "Hirsch- 
sprung's disease,"  is  applied  to  a  dilatation  which  usually  affects  the 
sigmoid  flexure  and  rarely  the  entire  large  intestine.  It  is  accom- 
panied by  hypertrophy  of  the  walls  of  the  dilated  portion  of  the  gut. 
No  cause  can  be  found  for  it.  Neither  a  contraction  at  either  end 
of  the  dilatation  or  any  other  organic  change  is  present.  Both  the 
anus  and  the  rectum  are  normal.  The  dilatation,  as  a  rule,  com- 
mences at  a  point  five  to  seven  centimeters  (about  two  inches) 


IDIOPATHIC  DILATATION  OF  THE  COLON  791 

above  the  rectum,  and  occasionally  higher  up.  The  sigmoid 
flexure  is  enormously  dilated  and  presents  the  appearance  of  a 
large  loop,  which  often  extends  upward  as  far  as  the  costal  arch. 
In  extreme  eases  the  dilatation  of  the  intestinal  coil  is  so  enormous 
that,  on  opening  the  abdomen,  the  other  contents  of  the  cavity 
are  entirely  concealed.  Cases  have  been  described  in  which  the 
diameter  of  the  gut  has  measured  fifteen  to  twenty  centimeters 
(five  to  seven  inches)  and  even  more.  The  descending  colon  does 
not  usually  participate  in  this  dilatation,  rarely  the  transverse 
portion,  and  the  ascending  colon  and  the  cecum  almost  never. 
The  small  intestine  is  normal  in  every  respect.  The  walls  of  the 
dilated  portion  of  the  intestine  are  markedly  thickened  and  dilated. 
This  thickening  is  caused  partly  by  hypertrophy  of  the  muscular 
layers  and  partly  by  hypertrophy  of  the  connective  tissue. 

The  etiology  of  this  disease,  first  fully  described  by  Hirschsprung, 
and  named  after  him,  is,  according  to  our  present  knowledge,  as 
follows:  There  is  originally  an  abnormal  length  and  dilatation  of 
the  sigmoid  flexure  (megacolon),  developed  during  fetal  life.  After 
birth  this  abnormality  induces  disturbances  in  defecation  which 
lead  to  muscular  hypertrophy  and  increasing  dilatation  of  the 
enlarged  portion  of  the  bowel.  When  there  are  at  the  same  time 
bendings  and  angulations  of  the  megacolon,  these  contribute  to 
the  further  retardation  of  intestinal  evacuation. 

A  large  proportion  of  the  cases  published  as  Hirschsprung's 
disease  are,  in  realit}',  merely  the  result  of  kinking  of  the  intestine, 
usually  at  the  sigmoid  flexure,  or  the  result  of  some  primary  or 
secondary  anomaly  in  the  mesentery.  The  assumption  of  a  con- 
genital deformity  is  sustained  by  the  finding  of  congenital  mal- 
formations in  other  parts  of  the  body  (see  page  561). 

The  anatomic  conditions  in  early  childhood  favor  this  kinking 
of  the  intestine,  and  any  disturbance  in  the  digestive  organs  is 
liable  to  cause  trouble  from  this  source.  The  sigmoid  flexure  in 
children  kinks  easily;  and  the  space  in  the  pelvis,  especially  in  boys, 
is  restricted,  as  compared  with  the  adult  anatomy.  Rectal  exam- 
ination is  important  for  differentiation;  in  cases  of  dilatation,  large 
amounts  of  fluid  can  be  introduced  without  flowing  out  again. 
Fluid  passes  readily  upward,  but  the  valve-like  closure  of  the  kinked 
intestine  prevents  its  escape.  The  Roentgen  ray  is  of  great  assist- 
ance in  the  diagnosis  (Plate  XXI,  Fig.  1,  Chapter  V). 

The  majority  of  cases  of  dilatation  of  the  colon  are  seen  in  young 
children,  but  the  condition  is  occasionally  observed  in  adults.  It 
is  a  peculiar  fact  that  boys  greatly  predominate  in  this  affection. 
One  of  the  very  early  signs  in  infantile  or  congenital  cases  is  irregu- 
larity in  the  evacuation  of  the  bowels.  There  exists  from  the 
beginning  an  idiosyncrasy  in  this  direction;  and  the  natural  consti- 
pation is  presently  followed  by  great  tension  and  enlargement  of 
the  abdomen.     The  majority  of  these  children  die  during  infancy, 


792         PERISIGMOIDITIS— DILATATION  OF  THE  COLON 

the  cause  being  either  intestinal  toxemia  or  acute  enteritis.  Occa- 
sionally, however,  the  indications  of  the  existence  of  any  disease 
are  so  slight  during  childhood  that  the  children  continue  to  live 
uneventfully,  and  the  disease  induces  serious  conditions  in  later 
years.  It  is  very  important  to  note  that  the  muscle  fibers  of  the 
dilated  intestine  soon  become  hypertrophied.  When  this  has  taken 
place,  intestinal  evacuation  may  remain  in  a  fairly  satisfactory 
condition,  the  disturbances  being  confined  to  a  slight  degree  of 
constipation,  with  no  alarming  symptoms.  But  when  the  hyper- 
trophy does  not  develop  sufficiently,  the  children  generally  succumb 
during  the  first  year  of  life.  It  is  probably  correct  to  assume  that 
idiopathic  dilatation  of  the  colon  is  the  cause  of  death  in  the  case 
of  many  children  who  die  during  the  first  year  of  life  with  symptoms 
of  constipation  and  without  any  very  clear  clinical  demonstration 
of  the  anatomic  abnormality. 

Symptoms . — The  characteristic  clinical  symptom,  as  intimated 
above,  is  the  persistence  of  constipation,  commencing  with  the 
birth  of  the  child,  and  necessitating  the  aid  of  purgative  medication 
or  enema ta.  The  feces  may  be  soft,  but  occasionally  inside  the 
dilated  portion  of  the  intestinal  canal  there  is  found  a  fecal  mass 
of  extreme  hardness.  There  may  be  symptoms  of  an  advanced 
stage  of  fecal  decomposition.  In  such  conditions  purgative  drugs 
are  decidedly  less  effective  than  enemata.  The  escape  of  offensive 
flatus  is  frequent.  Notwithstanding  the  good  appetite  and  the 
ingestion  of  plenty  of  food,  the  state  of  nutrition  becomes  impaired 
in  consequence  of  toxemia  incident  to  the  decomposition  processes 
and  the  constipation.  The  patients  become  emaciated.  When 
muscular  hypertrophy  has  become  well  established,  the  bowels 
may  be  able  to  expel  the  accumulated  fecal  masses  from  time  to 
time,  either  spontaneously  or  with  the  assistance  of  appropriate 
measures.  These  are  the  cases  in  which  life  can  be  prolonged  into 
more  advanced  age.  But  when  the  irregularities  in  the  bowel 
movements  are  more  strongly  developed  they  frequently  induce 
violent  colics  and  symptoms  of  stenosis.  The  abdomen  continues 
to  be  more  and  more  distended,  the  lower  ribs  are  pushed  outward, 
the  lower  portion  of  the  abdomen  on  the  left  side  protrudes  con- 
siderably, and  the  veins  of  the  skin  over  the  abdomen  become 
dilated.  The  liver  and  the  heart  dulness,  together  with  the  dia- 
phragm, are  widely  displaced  upward,  and  it  is  often  possible 
to  see  the  outlines  of  the  enlarged  intestinal  loop  beneath  the 
abdominal  wall.  As  a  rule  nothing  abnormal  can  be  felt  per 
rectum.  The  feces  gradually  continue  to  increase  in  offensiveness. 
Very  often  they  contain  blood  and  pus,  from  ulcerations  (dis- 
tention ulcers)  of  the  mucous  membrane.  The  toxemic  symptoms 
become  more  pronounced  in  proportion  to  the  difficulty  experienced 
in  evacuating  the  bowels.  Finally  the  patients  die,  either  of  this 
disease  or  of  an  intercurrent  acute  enteritis. 


IDIOPATHIC  DILATATION  OF  THE  COLOh  793 

When  the  patients  survive  the  period  of  infancy,  the  prognosis 
is  better.  The  compensatory  muscular  hypertrophy  is  capable  of 
overcoming  the  fecal  stagnation  for  a  considerable  length  of  time, 
and  the  growth  of  the  patient  in  a  certain  sense  repairs  the  damage. 
The  mesentery  ceases  to  grow,  undergoes  shortening,  and  hold-  the 
dilated  intestinal  loop  in  the  pelvic  cavity.  The  mortality,  however, 
even  in  more  advanced  age.  amounts  to  51  per  cent. 

Treatment. — The  internal  treatment  of  idiopathic  dilatation  of 
the  colon  is  symptomatic  only,  and  its  principal  purpose  should  be 
to  prevent  the  stagnation  of  feces.  All  the  measures  adapted  to 
the  treatment  of  chronic  constipation  serve  this  purpose,  but  more 
particularly  should  copious  irrigations  be  made  with  the  fluids 
mentioned  in  Chapter  XI;  yet  these  irrigations  will  not  be  effective 
unless  the  rectal  tube  is  pushed  up  a  considerable  distance  from  the 
anus.  In  order  to  prevent  bending  of  the  rectal  tube,  it  is  well  to 
guide  it  with  the  finger  inserted  alongside.  When  the  fecal  masses 
are  very  hard  it  may  become  necessary  to  undertake  their  direct 
manual  evacuation ;  in  this  wray  enormous  quantities  of  decomposing 
material  are  sometimes  removed.  The  distention  of  the  abdominal 
cavity  and  the  colicky  pains  may  be  diminished  by  the  introduction 
of  a  rectal  tube,  thus  facilitating  the  escape  of  gas.  Many  authors 
caution  against  the  administration  of  purgatives  by  mouth,  espe- 
cially drastics.  These  often  aggravate  the  condition,  particularly 
when  the  sigmoid  flexure  shows  marked  convolutions  and  angular 
bendings.  A  few  clinicians  have  observed  good  effects  from  the 
internal  administration  of  senna,  rhubarb,  and  strychnin. 

The  diet  corresponds,  on  the  whole,  to  that  prescribed  for  cases 
of  spastic  constipation  (see  Chapter  VII).  The  chief  requisite  is 
that  it  yield  little  residue,  thus  limiting  the  amount  of  fecal  material 
formed. 

These  measures  are  to  be  supplemented  by  hydrotherapeutic 
applications,  such  as  Priessnitz  bandages,  warmth  to  the  abdomen, 
hot  packs,  and  sitz  baths.  A  regular  abdominal  massage  and  the 
percutaneous  or  intrarectal  application  of  the  faradic  current  are 
useful  at  times  (see  Chapter  X). 

On  account  of  the  limitations  of  internal  therapeutics  in  this 
class  of  cases,  surgical  intervention  has  been  undertaken — with 
rather  satisfactory  results  in  manv  instances. 


CHAPTER  LII. 
THE  ANIMAL  PARASITES  OF  THE  INTESTINE. 

TAPEWORMS. 

The  tapeworm,  a  member  of  the  group  of  cestodes,  is  found  very 
frequently  in  man. 

Taenia  Saginata. — The  most  common  form  of  tapeworm  seen  in 
the  United  States  is  the  Taenia  saginata,  or  mediocanellata  (Fig. 
114).  It  may  be  identified  by  its  extensive  branched  uterus  and 
lateral  genital  pores,  and  its  head  with  four  suction  depressions 
without  a  corona  or  hooks  (Fig.  115,  a).  Its  presence  in  man  is 
proved  by  demonstration  of  its  eggs  (Figs.  115,  c)  and  by  the  dis- 
charge of  proglottides  (Fig.  115,  b)  or  segments  of  the  worm  in  the 
feces;  the  segments  are  often  evacuated  independently  of  the  feces. 
Taenia  saginata,  or  the  "unarmed  tapeworm,"  enters  the  intestine 
through  the  eating  of  measly  beef. 

Taenia  Solium. — The  Taenia  solium  is  more  rare,  and  may  be 
identified  by  its  slightly  branched  uterus  with  lateral  genital  pores 
(Fig.  117,  c).  Its  head  has  four  suction  facets  with  a  corona  of 
hooks  (Figs.  116  and  118).  Proof  of  the  presence  of  this  worm 
in  the  intestine  by  the  demonstration  of  ova  in  the  feces  is  more 
difficult  than  in  the  case  of  Taenia  saginata,  because  the  eggs  are 
not  deposited  so  frequently  (Fig.  119).  Isolated  segments  and 
connected  pieces  of  the  worm  itself  are,  however,  occasionally 
discharged.  Taenia  solium,  or  the  "armed  tapeworm,"  is  acquired 
by  eating  measly  pork. 

Bothriocephalus  Latus.— The  next  variety  of  tapeworm  occurring 
in  man  is  the  Bothriocephalus  latus  (Fig.  120),  which  is  particularly 
frequent  in  Holland  and  the  Baltic  countries.  Bothriocephalus 
latus  contains  many  proglottides,  and  is  recognized  by  its  short 
broad  segments,  its  small,  slightly  branched  uterus  and  median 
genital  pores,  and  the  oval  head  with  two  lateral  suction  facets 
(Figs.  121  and  122).  The  ova  of  the  Bothriocephalus  latus  may  be 
easily  demonstrated  in  the  feces;  they  are  characterized  by  a  lid- 
like covering  at  one  extremity.  Bothriocephalus  latus,  or  the 
"broad  Russian  tapeworm,"  is  acquired  by  eating  measly  fish. 

Hymenolepis  Nana. — There  is  another  tapeworm  that  is  fre- 
quently found  in  certain  parts  of  the  United  States.  The  Hymeno- 
lepis nana,  the  dwarf  tapeworm  (Figs.  123  to  128),  is  a  small 
tapeworm,  less  than  two  inches  (5  to  45  mm.)  in  length.  It  has 
four  suckers  with  a  corona  of  hooks  on  the  head,  and  the  genital 


TAPEWORMS 


795 


])i»rcs  arc  Lateral. "  This  tapeworm  inhabits  the  ileum,  and  there  may 
be  a  single  parasite  or  several  thousand  present.    The  detached  seg- 

inents  of  this  worm  are  so  small  that  they  easily  escape  detection. 
With  the  microscope  the  characteristic  eggs  can  easily  be  found  in 
the  stools,  Itats  and  mice  arc  regular  hosts  for  this  worm.  The 
eggs  may  be  carried  to  the  food  through  the  droppings  of  mice 
and  rats  on  their  visits  to  the  pantry. 

There  are  also  Twain  ii/urfa  ga.scariensis,  Taenia  flavopu aetata, 
Tarda  (nwumerina,  Bothriocephalus  cordatus,  and  other  tapeworms, 
all  of  which  are  rarely  met  with  in  the  United  States. 

Mode  of  Infection.—  The  mode  of  infection  with  these  tapeworms 
is  by  the  original  ova  entering  an  intermediate  host,  developing  into 
cysticerci,  and  passing,  with  the  flesh  of 
their  host  (as  contaminated  meat),  into  the 
stomach  and  intestine  of  the  patient. 
Thorough  boiling  of  the  meat  destroys 
them.  The  intermediate  host  for  the  Taenia 
mediocanellata  is  beef;  for  the  Taenia  so- 
lium, pork;  for  the  Bothriocephalus  latus, 
pike,  and  frequently  salmon.  In  the  case 
of  the  Taenia  solium  the  ^patient  himself 


Fig.  114. — Taenia  saginata, 
natural  size.     (Guiart.) 


a  b  ( 

Fig.     115. — Taenia    saginata.     a,    head 
enlarged;     b,     developed     proglottis;     c, 
(Schmidt  and  Strasburger.) 


much 


may  be  both  mediate  and  intermediate  host,  the  cysticerci  becom- 
ing attached  to  a  number  of  organs. 

It  frequently  happens  that  the  Taenia  saginata  and  Taenia  solium 
do  not  cause  any  symptoms  of  disease,  except  that  the  segments  are 
discharged.  In  a  few  cases  there  are  abdominal  pains,  irregular 
evacuation  of  the  bowels,  vomiting,  lassitude,  mental  depression, 
loss  of  appetite,  and  headache.  These  symptoms  disappear  after 
the  expulsion  of  the  parasite. 

The  Bothriocephalus  latus  is  apt  to  induce  more  serious  symp- 
toms, even  grave  anemia  similar  to  pernicious  anemia.     We  now 


796 


ANIMAL  PARASITES  OF   THE  INTESTINE 


know  this  anemia  is  dependent  upon  certain  lipoid  substances  con- 
tained in  the  bothriocephalus,  which  gaining  access  to  the  blood 
produce  hemolytic  effects. 

The  symptoms  are  very  mild  or  entirely  absent  in  cases  of  infec- 
tion with  Hymenolepis  nana.  The  most  frequent  symptoms  are 
abdominal  pain  associated  with  diarrhea  and  headache.  Nasal 
or  anal  pruritus,  common  in  cases  of  infection  with  other  tapeworms, 
is  rarely  seen  with  Hymenolepis  nana. 


Fig.  116, 


-Head  of  Taenia  solium.    X  45. 
(Leuckart.) 


Fig.  117. — Segment  of  Taenia  solium. 


Fig.  118. — Hooklets  of  Taenia  solium. 


Fig.  119. — Ovum  of  Taenia  solium. 


In  making  a  diagnosis  the  finding  of  segments  or  the  parasitic 
ova  in  the  feces  is  decisive.  Besides  the  usual  direct  microscopic 
method  of  examination,  Yaoita's  method  should  be  employed :  Take 
from  five  different  parts  of  the  stool  a  piece  of  fecal  matter  about 
the  size  of  a  pea;  place  in  a  test  tube  with  a  mixture  of  25-per-cent. 
antiformin  and  ether  in  equal  parts,  and  shake  vigorously.  The 
feces  dissolve  largely  in  this  reagent,  with  the  evolution  of  gas. 
The  solution  is  now  filtered  through  a  hair  filter  to  remove  the  large 
food  particles,  the  filtrate  is  centrifugalized  one  minute,  and  the 
sediment  contains  the  ova  in  addition  to  the  insoluble  parts  of  the 
feces.  This  method  of  examination  will  yield  positive  results  when 
the  direct  microscopic  examination  is  negative. 


TAPEWORMS 


797 


Treatment.  Tapeworms  cannot  be  removed  by  simple  purgatives; 
they  require  anthelmintics.  The  action  of  these  remedies  lias  not 
as  yet  been  entirely  elucidated  in  all  its  details.    They  probably 

act  as  specific  poisons  on  the  protoplasm  of  the  parasites.  The 
fact  that  all  of  them  are  difficult  of  absorption  from  the  intestine 
facilitates  this  effect. 


Fig.  121.— Enlarged  head  of  Bothrio- 
cephalus latus.     (Guiart.) 


Fig.  120. — Bothriocephalus  latus.  a, 
head  and  neck;  b,  c,  d,  e,  f,  segments 
taken  from  different  parts;  g,  shrunken 
segments  after  the  laying  of  the  eggs. 
(Guiart.) 


Fig.    122. — Transverse  section  of  head 
of  Bothriocephalus  latus.     (Guiart.) 


The  most  extensively  employed  tapeworm  remedy  is  the  oleo- 
resin  of  the  root  of  the  male  fern,  oleoresina  aspidii.  The  active 
principle  is  the  filicic  acid,  which  is  readily  converted  into  an  inactive 
crystalline  anhydrid.  This  transformation  takes  place  particularly 
in  old  roots,  and  explains  why  the  extract  from  fresh  roots  is  more 
active.  The  oleoresin  of  male  fern  is  poisonous,  and  it  is  there- 
fore necessary  to  insist  on  exact  dosage;  cases  of  fatal  poisoning 
have  been  observed,  preceded  by  convulsions,  visual  disturbances, 
blindness,  paralysis,  and  diarrhea.  The  adult  dose  of  oleoresina 
aspidii  is  2  to  8  Cc.  (5ss-ij);  of  the  root  itself,  about  20  Gm.  (5v). 
Sensitive  patients  may  take  the  oleoresin  in  gelatin  capsules. 


798 


ANIMAL  PARASITES  OF' THE  INTESTINE 


Filmaron  is  the  trade  name  for  the  isolated  active  principle  of 
the  root  of  male  fern.  The  dose  for  adults  is  1  Gm.  (15  grains), 
for  children  0.3  to  0.5  Gm.  (5  to  8  grains). 


Fig.  123 


Fig.  124 


Fig.  125 


Fig.  126 


Fig.  127 


Fig.  128 


Hymenolepis  nana.    Fig.  123,  body;  124,  natural  size;  125,  head;  126,  hooklets;  127, 
eggs;  128,  egg,  magnified  600  times.      (From  Mosler.) 

Cortex  granati  is  used  nearly  as  frequently  as  male  fern.     It  is 
the  bark  of  a  pomegranate  tree  (Punica  granatum).     The  active 


TAPEWORMS  799 

constituent  of  the  bark  is  the  alkaloid  pelletierin.     Pelletierin  itself 

lias  been  employed  as  an  anthelmintic,  with  satisfactory  results.  To 
diminish  its  solubility  and  thus  prevent  its  absorption,  tannic  acid 
is  sometimes  added  to  it. 

Gm.  or  Cc. 

fy— Pellet icrini 0|8  gr.  xij 

Acidi  t  amiici 0 1 5  gr.  viiss 

Aquae 30 10  5j 

Misce. 
Sig. — To  be  taken  in  one  dose  in  the  morning,  and  a  tablespoonful  of  castor 
oil  two  hours  later. 

Pumpkin  seeds  (Cucurbita  pepo)  are  particularly  adapted  for 
the  treatment  of  children.  Sixty  to  ninety  grams  (2  to  3  ounces) 
of  the  seeds,  deprived  of  integument,  are  triturated  thoroughly 
with  sugar,  and  given  mixed  with  milk.  The  dose  is  to  be  taken 
the  first  thing  in  the  morning  on  an  empty  stomach.  Two  hours 
later  a  teaspoonful  to  a  tablespoonful  of  castor  oil  is  given. 

All  the  above  medicaments  are  effective  only  when  fresh.  The 
active  ingredients  undergo  decomposition  after  a  time.  Anthelmin- 
tics are  nerve  poisons,  and  it  is  therefore  necessary  to  be  particularly 
careful  and  exact  in  the  dosage. 

Systematic  treatment  should  be  undertaken  only  after  the 
physician  has  ascertained  positively  that  a  tapeworm  is  actually 
present  by  the  demonstration  of  its  ova  in  the  feces  or  by  the  finding 
of  isolated  segments. 

The  attempt  to  expel  a  tapeworm  from  the  intestine  is  frequently 
unsuccessful.  The  commonest  cause  of  failure  is  that  the  intestine 
has  not  been  thoroughly  evacuated  beforehand.  To  secure  the  best 
action  of  the  anthelmintic,  the  bowel  should  be  as  nearly  empty 
as  possible,  not  only  of  food  but  also  of  the  large  amount  of  mucus 
which  is  usually  present. 

Before  an  anthelmintic  is  administered,  at  least  two  days  should 
be  devoted  to  the  preparation  of  the  patient  for  the  treatment. 
The  patient  should  give  up  his  business  and  attend  strictly  to 
the  preparatory  treatment.  The  diet  should  be  liquid:  milk, 
not  more  than  a  quart;  beef  tea,  and  coffee  if  desired.  During 
these  two  days  the  patient  should  receive  a  dose  of  magnesium 
sulphate  4  Gm.  (5  j)  three  times  a  day,  in  water,  so  that  the  upper 
part  of  the  intestine  may  be  thoroughly  cleansed,  especially  of  mucus. 
This  may  also  be  accomplished  by  a  single  dose  of  calomel,  0.3  to  0.5 
Gm.  (5  to  8  grains),  or  two  tablespoonfuls  of  castor  oil  at  night. 
The  next  morning  the  patient  should  take  the  oleoresin  aspidium; 
as  a  rule,  a  dose  of  8  Gm.  (5  ij)  is  large  enough  for  an  adult.  This 
dose  should  be  taken  in  its  entirety,  best  in  cold  black  coffee,  fol- 
lowed in  one  or  two  hours  by  a  vigorous  purge,  preferably  castor 
oil  in  the  dose  of  twro  tablespoonfuls. 

The  patient  may  take  half  the  prescribed  dose  of  oleoresin,  an 
hour  later  a  tablespoonful  of  castor  oil,  in  another  hour  the  balance 


800  ANIMAL  PARASITES  OF   THE  INTESTINE 

of  the  oleoresin,  and  again,  an  hour  later,  a  second  tablespoonful 
of  castor  oil.  After  the  administration  of  male  fern  and  castor  oil 
a  few  cases  of  poisoning  have  been  observed,  and  it  has  been  assumed 
that  the  castor  oil  had  assisted  the  poisoning.  The  filicic  acid  in 
the  male  fern  is  said  to  be  soluble  in  oil  and  therefore  more  likely 
to  become  absorbed.  This  effect  of  castor  oil  has  not,  however, 
been  conclusively  demonstrated.  It  is  more  probable  that  in 
these  cases  the  filix  alone  was  to  blame,  without  the  castor  oil, 
since  impure  male  fern  is  particularly  apt  to  cause  poisoning. 
Nothing  can  be  adduced  against  the  administration  of  castor  oil 
after  male  fern.  There  is,  of  course,  no  objection  to  substituting 
calomel  or  bitter  mineral  water  for  the  castor  oil.  In  order  to 
reduce  the  quantity  of  oleoresin  necessary  for  a  cure,  the  medica- 
ment has  been  administered  combined  with  chloral  hydrate,  2  Gm. 
(5ss)  of  the  former  to  1.5  Gm.  (22|  grains)  of  the  latter,  followed 
by  a  powerful  drastic  purgative,  and  good  effects  have  resulted. 

Very  sensitive  persons  may  take  the  oleoresin  aspidium  and  the 
castor  oil  in  gelatin  capsules,  in  order  to  prevent  loss  of  the  remedy 
from  vomiting. 

Oleoresin  of  male  fern  is  given  to  children,  according  to  age,  in 
doses  of  1  to  4  Gm.  (15  to  60  grains). 

ASCARIS  LUMBRICOIDES  (ROUND  WORM). 

A  parasite  that  frequently  infests  the  human  intestine  is  the 
Ascaris  lumbricoides  (Fig.  129),  or  round  worm,  belonging  to  the 
family  of  Nematodes.  The  round  worm  is  of  a  reddish  or  brownish 
color,  about  |  inch  in  diameter — the  size  of  a  small  goose-quill. 
The  male  varies  in  length  from  4  to  8  inches,  the  female  from  6 
to  12.  The  male  is  the  more  curved,  the  female  the  straighter 
of  the  two.  It  has  been  estimated  that  the  genital  tubes  of  a  large 
mature  female  ascaris  may  contain  60,000,000  eggs.  The  eggs  after 
passing  from  the  intestine  are  exceedingly  tenacious  of  life;  they 
may  survive  as  long  as  two  or  three  years.  The  ova  may  be  taken 
into  the  stomach,  where  in  the  course  of  one,  two  or  three  weeks 
the  worm  is  hatched  out.  The  eggs  are  characteristic;  their  interior 
consists  of  a  granular  mass,  surrounded  by  a  thick  double  shell 
and  an  albuminoid  coating  (Fig.  129,  C). 

Infection  usually  takes  place  by  way  of  the  patient's  mouth.  An 
intermediary  host  is  not  necessary. 

Symptoms. — In  many  cases  no  symptoms  whatever  are  produced 
by  the  ascarides  lumbricoides.  Occasionally  abdominal  pains  and 
nervous  symptoms  are  present  as  in  cases  of  tapeworm. 

Diagnosis. — As  an  aid  to  diagnosis  it  should  be  remembered  that 
an  increased  number  of  eosinophiles  in  the  blood  indicates  possible 
infection  with  animal  parasites.  When  this  is  found  in  the  course 
of  routine  examination,  we  should  institute  a  search  for  the  eggs  or 


|m  WlilS   LVMliUK'OlDES 


Mil 


embryos  of  parasites  in  the  feces. 
IV  la  Fuente  points  out  two  signs 
which  establish  the  diagnosis  of  in- 
testinal helminthiasis  without  exam- 
ination oi  the  stools.  One  is  the 
occurrence  of  colicky  attacks  coming 
on  very  suddenly,  seizing  the  child 
in  the  midst  of  play,  quite  severe  at 
the  outset,  and  confined  to  one  part 
of  the  abdomen;  all  the  rest  of  the 
abdomen  may  be  palpated  without 
causing  the  slightest  pain,  but  the 
moment  the  seat  of  the  colic  is 
touched  the  child  will  cry.  The 
other  is  bilateral  narrowing  of  the 
visual  field,  usually  so  pronounced 
as  to  be  detected  by  passing  the 
finger  to  and  fro  before  each  of  the 
patient's  eyes. 

Couillaud  has  described  a  specific 
sign  of  the  tongue  found  in  helmin- 
thiasis. In  cases  of  ascarides  and 
oxyuris  the  fungiform  papillae  are 
hypertrophied.  At  the  base  of  the 
tongue  are  seen  scattered  red  points 
which  are  also  diffused  along  the 
sides  and  at  the  tip. 

In  rare  instances  grave  complica- 
tions are  induced  by  a  round  worm 
perforating  the  intestine.  Should 
one  become  incarcerated  in  the  duc- 
tus choledochus  or  the  gall  bladder, 
grave  jaundice  and  cholangitis  might 
follow  (see  page  016). 

The  evidence  shows  that  the  as- 
caris  is  able  to  perforate  the  intes- 
tinal wall,  especially  when  favored 
by  tuberculous,  typhoid  or  other 
ulcerative  lesions.  The  biliary  sys- 
tem also  should  be  borne  in  mind, 
particularly  in  the  case  of  children 
or  adults  who  are  known  to  have 
worms  and  wTho  have  at  the  same 
time  chronic  jaundice,  convulsions, 
fever,  violent  pain  in  the  region  of 
the  liver,  or  symptoms  of  hepatic- 
abscess. 

Treatment.  —  The    remedy   most 
frequently  employed  and  with  the 
51 


(F) 


rZ>!, 


£4 


B 


Fig.  129.  —  Ascaris  lumbricoides. 
A,  female;  B,  male;  C,  egg;  at  a  the 
female  genital  opening;  c,  the  male 
spicules;  b,  the  enlarged  cephalic 
extremity,  with  its  three  lips. 
(After  Perlo,  from  Ziegler.) 


802  ANIMAL  PARASITES  OF   THE  INTESTINE 

greatest  expulsive  efficacy  is  santonin.  Santonin  is  a  nerve  poison 
and  in  large  doses  induces  sensory  disturbances,  especially  of  the 
eye,  violet  and  yellow  colors,  hallucinations,  lowering  of  temperature, 
lassitude,  convulsions,  and  paralysis  of  respiration.  The  urine, 
after  santonin  has  been  taken,  is  greenish-yellow  and  contains  a 
substance  which  turns  purple-red  on  the  addition  of  concentrated 
sodium  hydrate  solution.  This  color  does  not  fade  on  the  addition 
of  ether,  thus  differing  from  the  urine  pigmentation  that  follows  the 
use  of  rhubarb  and  senna.  An  important  differential  point  is  thus 
afforded  in  the  diagnosis  of  poisoning  by  santonin. 

The  dose  of  santonin  for  children  between  the  ages  of  one  and 
eight  years  is  0.01  to  0.03  Gm.  (§•  to  \  grain),  not  exceeding  0.06  to 
0.1  Gm.  (1  to  2  grains)  in  one  day.  The  maximum  single  dose  for 
adults  is  0.1  Gm.  (2  grains);  the  maximum  amount  per  day,  0.5 
Gm.  {1\  grains) .  Usually  the  first  dose  is  given  early  in  the  morning, 
and  in  case  round  worms  are  expelled  the  medication  is  continued 
during  that  day  and  part  of  the  next.  Santonin  is  best  given  in 
powder  with  castor  oil: 

Gm.  or  Cc. 

1$ — Santonin! Oil  gr.  ij 

Olei  ricini 15  j 0  §ss 

Misce. 

Sig.- — One  dessertspoonful  (warmed)  to  be  taken  in  the  morning. 

Or  it  may  be  combined  with  calomel: 

Gm.  or  Cc. 

1$. — Santonini 0 1 3  gr.  v 

Hydrargyri  chloridi  mitis  ....       0  ]  06  gr.  j 

Sacchari  albi 1 1 5  gr.  xxiij 

Misce  et  ft.  pulv.  no.  iii. 

Sig. — -Three  powders  to  be  taken  within  three  hours  in  the  morning. 

There  are  also  santonin  tablets  (trochisci  santonini),  each  con- 
taining 0.03  Gm.  (§  grain),  which  may  be  given  to  either  adults 
or  children.     Give  castor  oil  a  few  hours  later. 

On  account  of  its  non-toxic  properties,  oleum  chenopodii  (Amer- 
can  wormseed)  is  warmly  recommended  in  place  of  santonin.  It  is 
said  to  be  equally  efficacious  and  free  from  the  disadvantages  that 
pertain  to  santonin.  The  oil  is  administered  either  pure  or  in  the 
form  of  an  emulsion: 

Gm.  or  Cc. 

1$ — Olei  chenopodii 5|0  5j 

Misce. 
Sig. — Eight  to  fifteen  drops  to  be  taken  in  sweetened  water  two  or  three 
times,  at  intervals  of  one  hour. 

Gm.  or  Cc. 

1$ — Olei  chenopodii, 

Pulveris  tragacanthse    .      .      .      .   aa       5 1 0  5  j 

Aquae  destillatse, 

Syrupi  aurantii aa     45 1 0  o  iss 

Misce  et  ft.  emulsio. 
Sig. — One  dessertspoonful  to  be  taken  two  or  three  times  within  two  hours. 


OXYURIS   VERMICULARIS  803 

As  the  oil  has  a  nauseating  taste,  it  is  advisable  to  follow  the 
dose  with  a  sip  of  milk,  sweetened  water,  or  dilute  raspberry  juice. 
One  or  two  hours  after  the  oil  has  been  taken,  a  purgative  should  be 
administered. 

OXYURIS  VERMICULARIS. 

(Pin  Worm — Thread  Worm — Seat  Worm — Maggot  Worm — AwUail.) 

Oxyuris  vermicularis  is  the  well-known  small  white  thread 
worm.  The  males  are  4  millimeters  (£  inch)  long,  and  the  females 
9  to  12  millimeters  (£  to  £  inch)  (Figs.  130  and  131).  The  worms 
occur  in  patients  of  all  ages,  but  most  often  in  children.  The 
infection  is  brought  about  by  ingestion  of  the  ova  (Fig.  132), 
the  patient's  fingers  harboring  the  parasite,  to  which  the  ova 
adhere,  and  thus  contaminating  the  food,  so  that  entire  families 
are  occasionally  infected.  The  period  of  development  of  the  worms 
in  the  stomach  is  about  five  weeks.  The  young  worms  here  escape 
from  the  eggs  and  migrate  into  the  small  intestine,  where  they  grow 
to  sexual  maturity.  Reproduction  occurs  in  the  lower  portions 
of  the  small  intestine,  in  the  cecum,  and  in  the  vermiform  appendix. 
The  largest  quantity  of  thread  worms  is  found  usually  in  the  cecum 
and  appendix.  The  ova  develop  in  the  fertilized  female,  and  the 
latter  migrates  downward  through  the  large  intestine  as  far  as  the 
rectum,  where  she  deposits  her  eggs  either  upon  the  feces  or  upon 
the  mucous  membrane;  the  larger  portion,  however,  is  either 
deposited  outside  of  the  intestine  or  carried  there — in  the  neigh- 
borhood of  the  anus  and  the  perineum.  After  depositing  her  eggs 
the  female  dies.  It  seems  as  if  these  worms  were  capable  of  pene- 
trating into  the  mucous  membrane  of  the  small  intestine,  especially 
when  this  membrane  is  pathologically  altered,  dying  there  and 
undergoing  calcification.  According  to  rather  recent  researches, 
calcareous  nodules  about  the  size  of  a  pin's  head  are  found  in  the 
intestinal  mucous  membrane,  corresponding  to  the  follicles  of 
Peyer's  patches  and  the  solitary  follicles,  at  the  bottom  of  which 
the  oxyurides  are  found.  According  to  modern  views,  these  para- 
sites may  cause  appendicitis  (see  page  767). 

Symptoms. — When  the  worms  are  numerous  the  symptoms  are 
apt  to  be  quite  pronounced.  There  is  a  most  tormenting  itching 
in  the  rectum  and  in  the  region  of  the  anus,  which  occasionally 
renders  the  patients  quite  desperate.  This  itching  is  probably 
induced  by  the  movements  of  the  migrating  worms,  and  is  particu- 
larly violent  at  night  from  the  warmth  of  the  bed.  As  the  pruritus 
ani  becomes  intolerable  the  patients  endeavor  to  relieve  themselves 
by  scratching  the  itching  spots.  Both  children  and  adults  indulge 
in  this  habit  with  equal  energy,  and  as  a  result  excoriations  of  the 
skin  are  frequently  found  in  the  anal  region.  In  girls  the  oxyurides 
may  creep  into  the  vagina,  inducing  vaginitis,  with  itching,  leading 
occasionallv  to  masturbation. 


804 


ANIMAL  PARASITES  OF  THE  INTESTINE 


There  may  be  other  symptoms,  as  pains  in  the  abdomen,  capri- 
cious and  sometimes  ravenous  appetite  (in  spite  of  which  the  child 
becomes  thin  and  sallow),  grinding  of  the  teeth  at  night,  picking 
of  the  nose,  nausea,  dizziness  and  other  reflex  phenomena,  irregu- 
larity of  the  bowels,  or  diarrhea. 


Fig.  131. — Oxyuris  vermicularis.  a, 
male;  b,  female,  natural  size;  c,  female, 
magnified. 


Fig.  130. — Oxyuris  vermicularis.  a, 
sexually  mature  female;  b,  female  filled 
•with  eggs;  c,  male.  X  10.  (After 
Heller,  from  Ziegler.) 


Fig.  132. — Eggs  of  Oxyuria  vermicu- 
laris in  various  stages  of  development. 
a,  b,  c,  division  of  the  yolk;  d,  tadpole- 
like embryo;  e,  worm-shaped  embryo. 
X  250.  (After  Zenker  and  Heller,  from 
Ziegler.) 


Diagnosis.- — The  diagnosis  is  established  by  the  discovery  of 
ova  of  the  Oxyuris  vermicularis  in  the  feces  or  by  demonstration 
of  the  expelled  worms  themselves.  It  is  frequently  necessary  to 
examine  the  material  collected  under  the  finger-nails  of  children,  as 
it  may  be  possible  thus  to  demonstrate  microscopically  the  eggs 
or  parts  of  the  worms. 


OXYURIS   VERMICULARIS  805 

Treatment.    The  objecl  of  the  txeatmenl  i^  to  remove  the  young 

brood  from  the  small  intestine,  to  clear  the  large  intestine  of  a<lnlt 
parasites,   and    to   protect   the   patient    from   fresh    infection.     The 

removal  of  the  young  worms  is  accomplished  by  purgatives  or 
vermifuges,  and  the  cleansing  of  the  large  intestine  is  attained  by 
appropriate  enemata.  The  more  rapidly  the  treatment  is  carried 
to  completion,  the  better  it  is  for  the  patient;  short  treatments 
generally  give  better  results  than  protracted  ones.  The  following 
five  days'  treatment  for  adults,  as  outlined  by  Zinn,  gives  excellent 
results: 

First  Day:  A  light  fluid  or  semisolid  diet.  In  the  afternoon  at 
three  o'clock  the  following  is  to  be  taken: 

Gm.  or  Cc. 

1$ — Hydrargyri  chloridi  mitis, 

Pulvcris  jalapae        .      .      .      .      .   aa      0|5  gr.  viij 

Misce. 
Sig. — To  be  taken  at  three  o'clock. 

At  6  o'clock  an  enema  of  1  to  2|  liters  (quarts)  of  warm  0.2-per- 
cent, to  0.5-per-cent.  solution  of  soap  (U.  S.  P.).  By  this  method 
the  entire  gut  is  thoroughly  cleared  and  well  prepared  for  the  action 
of  the  vermifuge. 

Second  Day:  Liquid  diet,  wdth  some  buttered  rolls.  Early  in 
the  morning  one  cup  of  black  coffee.  In  the  forenoon  at  8,  10 
and  12  o'clock,  a  powder  containing  0.05  Gm.  (1  grain)  santonin 
and  0.1  Gm.  (2  grains)  calomel.  At  2  o'clock  in  the  afternoon  two 
tablespoonfuls  of  castor  oil,  to  be  repeated  if  necessary  at  4  o'clock. 

Third  Day:  Liquid  and  semisolid  diet.  Early  in  the  morning 
a  warm  full  bath.  In  the  forenoon  and  in  the  afternoon  an  enema 
(in  the  left  lateral  or  in  the  genupectoral  position)  of  1  to  2\  liters 
(quarts)  of  the  soap  solution  mentioned  above. 

Fourth  and  Fifth  Days:  Exactly  as  on  the  third  day.  In  the 
evening  a  warm  bath. 

Before  and  after  every  meal  the  hands  should  be  carefully  washed 
with  warm  water,  soap  and  brush,  and  disinfected  with  alcohol 
or  a  1:3000  sublimate  solution.  The  same  procedure  should  be 
followed  out  after  each  defecation,  and  the  region  of  the  anus 
should  always  be  carefully  washed.  The  medicines  are  to  be  taken 
between  the  meals.  In  order  ;to  prevent  continued  reinfection, 
the  patient  is  to  be  carefully  instructed  about  the  mode  of  the 
infection.  During  and  after  the  treatment  the  underwear  and  the 
bedclothes  should  be  frequently  changed. 

Apart  from  santonin,  any  of  the  other  vermifuge  medicaments 
may  be  employed  as  described  under  Treatment  of  Ascaris  Lum- 
bricoides.  The  doses  of  the  anthelmintics  and  the  size  of  the 
enemata  must  be  modified  according  to  the  ages  of  young  patients. 
The  pruritus  of  the  anus  and  its  neighborhood  may  be  treated  by 
inunctions  of  mercurial  ointment.  (See  Chapter  LIY  on  Pruritus 
Ani.) 


806  ANIMAL  PARASITES  OF   THE  INTESTINE 

The  soap  enemata  may  be  replaced  by  weak  infusions  of  quassia, 
lime-water,  9-per-cent.  acetic  acid,  20-per-cent.  vinegar-water,  cod- 
liver  oil,  naphthalan,  0.5-per-cent.  tannic  acid  solution,  salt  solution, 
glycerin-water,  or  thymol  oil  (thymol  1  to  olive  oil  100).  It  is  also 
advisable  to  add  anthelmintics  to  the  enemata.  For  this  purpose 
oleoresina  aspidii  may  be  especially  recommended;  it  is  triturated 
with  warm  thin  oatmeal  gruel,  and  sufficient  gruel  is  gradually 
added  to  make  1  to  1^  liters  (quarts)  for  an  enema. 

The  diet  during  the  treatment  should  be  semiliquid,  as  men- 
tioned above.  Raw  carrots  are  popularly  regarded  as  an  adjuvant 
in  the  expulsion  of  worms. 

The  treatment  as  here  detailed  is  usually  effectual  in  five  days. 

In  young  children  the  administration  of  the  enemata  is  occasionally 
troublesome,  and  on  this  accoimt  the  treatment  may  have  to  be 
continued  a  few  days  longer.  If  ova  and  single  specimens  of  the 
parasite  are  again  found,  the  treatment  may  be  repeated  once  or 
twice  after  a  week  or  two. 

ANKYLO STOMA  DUODENALE;  UNCINARIA  AMERICANA. 

(  Uncinariasis — Hookworm  Disease — Necator  Americanus — Miner's 

Anemia — Strongylus  Duodenalis —  Dochmius  Duodenalis — 

Uncinaria  Duodenalis — Ground-itch  Anemia.) 

The  Ankylostoma  duodenale  is  a  native  of  Egypt  and  Japan, 
which  later  made  its  appearance  in  Italy.  It  has  also  been  found  in 
the  last  few  years  in  Germany,  particularly  in  the  mining  districts. 
The  male  is  yellow,  7  to  10  millimeters  (J  to  I  inch)  long;  the 
female  brown,  10  to  18  millimeters  long  (Figs.  133  and  134).  The 
prehensile  apparatus  is  at  the  cephalic  extremity,  and  the  worms 
attach  themselves  by  hooking  upon  the  mucous  membrane  of  the 
intestine.  The  infection  is  usually  brought  about  by  transference  of 
the  eggs  through  contaminated  hands;  or  the  larvae  enter  through 
the  skin  (Fig.  135),  causing  a  condition  known  in  the  South  as 
"ground  itch,"  "foot  itch,"  "toe  itch"  and  "dew  itch."  In  the 
experience  of  Stiles,  87  per  cent,  of  hookworm  cases  definitely 
admit  a  history  of  ground  itch.  The  worm  thrives  in  the  jejunum 
and  the  upper  portions  of  the  ileum,  and  rarely  in  the  duodenum. 
It  feeds  on  the  blood  of  the  host.  According  to  more  recent  obser- 
vations the  worm  is  said  to  actually  eat  the  intestinal  epithelium. 

At  the  fifth  annual  meeting  of  the  American  Gastroenterological 
Association  in  1902,  Charles  Wardell  Stiles,1  of  the  Public  Health 
and  Marine  Hospital  Service,  called  attention  to  a  new  species 
of  parasitic  hookworm,  which  he  named  Uncinaria  americana. 
It  differs  from  Ankylostoma  duodenale  (Fig.  136)  chiefly  in  the 
following   characteristics:    Ventral   recurved  hook-like   teeth   are 

1  Stiles,  A  New  Species  of  Hookworm  (Uncinaria  americana)  Parasitic  in  Man, 
American  Medicine,  May  10,  1902,  p.  777. 


ANKYLOSTOMA   DUODEN ALE— HOOK  WoltU 


so: 


absent  from  the  mouth,  their  place 
being  taken  by  a  pair  of  semilunar 
plates  (Fig.  137);  a  dorsal  conical 
tooth  projects  prominently  into  the 
buccal  capsule;  dorsal  ray  or  caudal 
bursa  in  the  male  divided  to  its  base, 
each  branch  being  bipartite  at  its  tip ; 
vulva  in  anterior  half  of  female  body, 
but  near  the  equator.  The  eggs  of 
Ankylostoma  duodenale  are  about 
0.05  millimeter  (^-J-g-  inch)  long  and 
about  half  as  broad,  and  show  seg- 
mentation in  the  shape  of  two  or 
three  furrows,  whereas  the  eggs  of 
Uncinaria  americana  are  somewhat 
arger — 64  to  72  by  36  to  40  microns 
(Fig.  138). 

It  was  soon  found  that  hookworm 
disease  was  the  most  common  of  the 
infectious  diseases  in  the  South,  and 
the  cases  in  America  were  due  almost 
exclusively  to  this  newly  found  para- 
site, which  was  named  Necator  ameri- 
canus,  the  American  murderer.  The 
distribution  of  the  parasite  is  rather 
interesting.  During  one  week  Stiles 
collected  from  correspondence  6858 
cases.  The  infection  is  heaviest  or 
greatest  along  the  sand  area.  The 
next  heaviest  infection  occurs  in  the 
Appalachian  region,  and  in  general  the 
clay  land  regions  are  less  infected. 
Cases  are  found  in  other  parts  of  the 
country.  A  group  of  cases  was  found 
in  New  York  State,  all  the  individuals 


Fig.  133. — Male  of  Ankylostoma.  duodenale.  a, 
head;  b,  esophagus;  c,  gut;  d,  anal  glands;  e,  cervical 
glands;/,  skin;  g,  muscular  layer;  h,  excretory  pore; 
i,  tri-lobed  bursa;  k,  ribs  of  bursa;  I,  seminal  duct; 
m,  vesicula  seminalis;  n,  ductus  ejaculatorius;  o,  its 
groove;  p,  penis;  q,  penile  sheath.  Magnifications  20. 
(After  Schulthess,  from  Ziegler.) 


Fig.  134. — Ankylostoma 
duodenale,  male  and  female. 
Natural  size.  (From  M os- 
ier.) 


ANIMAL  PARASITES  OF   THE  INTESTINE 


being  United  States  soldiers  who  enlisted  in  the  Southern  States. 
Two  patients  were  from  Connecticut. 

Stiles  visited  about  one  hundred  and  thirty  cotton  mills  and  eight 
milling  camps  in  the  South,  and  found  many  men,  women  and 
children  in  the  mills  who  were  infected  with  hookworm  disease  to 
such  an  extent  that  the  diagnosis  could  be  made  without  the  aid  of 
the  microscope.  One  out  of  every  eight  of  the  cotton  mill  employees 
of  the  Southern  States,  if  we  accept  these  one  hundred  and  thirty 
as  fairly  representative,  has  hookworm  disease  so  obviously  that  the 
microscope  is  not  needed  in  the  diagnosis.  The  distribution  of  the 
disease  bears  an  inverse  relation  to  the  distribution  of  what  one 
might  call  the  efficiency  of  the  cotton  mill  labor.     If  one  enters  a 


Fig.  135. — -Section  through  the  skin  of  a  dog  within  two  hours  after  it  had  been 
infected  with  the  hookworm  (Ankylostoma  duodenale) .     Greatly  enlarged.     (Stiles.) 


Piedmont  mill  he  will  see  that  the  laborer  is  distinctly  more  efficient 
than  the  laborer  in  a  mountain  mill  or  a  sand-land  mill.  In  the 
sand-land  mills  the  infection  among  the  employees  runs  up  to  as  high 
as  50,  60  or  nearly  70  per  cent,  in  the  men,  women  and  children 
employed,  while  in  some  of  the  Atlanta  mills  it  drops  to  5  per  cent, 
or  even  to  zero.  Atlanta  is  in  a  clay  belt,  and  the  inhabitants  live 
under  good  sanitary  conditions. 

Hookworm  disease,  as  found  in  the  United  States,  has  been 
traced  to  the  west  coast  of  Africa,  even  as  far  as  the  pigmy  tribes. 
Unquestionably  the  negroes  must  have  brought  many  hookworms 
to  this  country.  The  disease  is  an  African  one,  which  has  been 
transmitted  to  the  whites.  The  negroes,  having  had  the  disease 
for  generations,  do  not  suffer  from  it  so  intensely  as  do  white  people. 


ANKYLOSTOMA    DCODEXALE     HOOKWORM 


809 


They  are  ambulant  cases,  carriers  of  the  infection,  and  of  necessity 

there  is  more  hookworm  disease  in  localities  where  negro  population 
predominates  largely.  Seventy-nine  per  cent,  of  the  negro  farm 
houses  which  Stiles  examined  and  tabulated  in  North  Carolina, 
South  Carolina,  Georgia,  Alabama,  and  Mississippi,  had  no  privy 
connected  with  them.  These  carriers  of  the  hookworm  suffer 
comparatively  little  themselves,  hut  serve  as  breeders  ot  the  worm 
and  sowers  of  its  seeds,  to  the  lasting  injury  of  their  white  neighbors. 
Cuba  and  Porto  Rico  have  many  cases  ot  uncinariasis,  and  thousands 
of  cases  are  reported  from  the  Philippines. 


Fig.  137. — Head  of  Uncinaria  ameri- 
cana,  showing  the  buccal  cavity  and 
semilunar  plates.     (Guiart.) 


Fig.  136. — Head  of  Ankylostoma 
duodenale.  a,  buccal  capsule;  b,  teeth  of 
capsule;  c,  teeth  of  dorsal  margin;  d, 
oral  cavity;  e,  ventral  prominence;  /, 
muscle  layer;  g,  dorsal  groove;  ft,  esoph- 
agus.    (After  Schulthess,  from  Ziegler.) 


Fig.  138. — Eggs  of  Ankylostoma  duo- 
denale. a-d,  various  stages  of  segmen- 
tation; e,  f,  eggs  containing  embryos. 
Magnification,  200.  (After  Ferroncito 
and  Schulthess,  from  Ziegler.) 


The  female  hookworm  lays  an  immense  number  of  eggs.  These 
eggs  are  excreted  with  the  feces  of  the  patient.  As  many  as  4000 
worms  have  been  found  in  one  patient,  and  as  many  as  2,000,000 
ova  may  be  discharged  in  a  single  stool.  Where  proper  conditions 
of  soil,  climate,  moisture  and  oxygen  prevail,  these  eggs  readily 
hatch  into  larva?.  The  larva?  are  exceedingly  minute,  unseen  by 
the  naked  eye;  they  infect  the  soil,  drinking-water,  and  food.  It 
has  been  demonstrated  that  the  eggs  and  larva?  may  be  carried  on 
the  legs  of  flies. 

Bentley  proved  hookworm  infection  to  be  due  to  the  entrance 


810  ANIMAL  PARASITES  OF  THE  INTESTINE 

of  the  larvae  of  the  ankylostoma  into  the  skin.  Loos1  also  proved 
that  the  larvae  could  penetrate  human  skin,  producing  a  local 
reaction,  and  that  men  and  dogs  could  acquire  the  disease  by  the 
cutaneous  route.  Boycott2  produced  an  infection  by  applying  a 
few  full-grown  larvae  to  the  skin  of  the  forearm  for  a  couple  of  hours. 
There  was  a  slight  local  reaction  and  some  itching,  and  eggs  were 
found  in  the  stools  after  fifty  days.  The  larvae  used  for  the  experi- 
ment were  a  single  batch  bred  for  the  purpose  from  infected  feces. 
Of  the  possibility  of  larvae  passing  through  the  skin,  and  ultimately 
reaching  the  bowel,  there  is  therefore  no  doubt  (Fig.  135).  The 
infection  of  the  feet  is  from  contact  with  the  soil,  which  becomes 
contaminated  by  the  deposition  of  the  laborer's  evacuations. 
The  larvae  present  in  the  skin  produce  an  itching  sensation  accom- 
panied by  an  inflammatory  reaction,  and  sometimes  secondary 
infection  with  other  microorganisms  may  take  place.  This  condi- 
tion is  commonly  known  as  ground-itch  or  dew-itch.  The  larvae, 
having  pierced  the  skin,  soon  gain  entrance  to  the  lymph  and  blood 
channels,  through  which  they  are  carried  to  the  heart  and  thence 
to  the  capillaries  of  the  lungs.  They  then  pass  through  the  capillary 
walls  into  the  alveolar  spaces;  from  here  they  migrate  through  the 
bronchioles  into  the  bronchi,  and  then  crawl  up  the  trachea  to 
reach  the  mouth  cavity,  after  which  they  are  swallowed  in  ordinary 
acts  of  deglutition,  eating,  drinking,  etc.,  and,  according  to  Linde- 
man,3  thereby  reach  the  intestinal  tract. 

Pathology. — In  hookworm  disease  the  jejunum  and  particularly 
the  ileum  are  the  seat  of  a  severe  catarrhal  process,  which  also 
affects  to  a  degree  the  other  portions  of  the  intestine.  There  is  a 
large  amount  of  mucus  in  the  intestinal  canal,  in  the  walls  of  which 
the  worms  are  embedded,  and  which  is  often  blood-stained  in 
places.  The  lesions  of  the  intestine  are  confined  to  the  mucosa, 
and  there  is  often  degeneration  and  atrophy  of  the  intestinal 
and  gastric  mucous  membrane.  At  the  point  of  attachment  of 
the  worms  there  is  a  tiny  erosion,  superficial,  not  deep,  and  about 
one-half  millimeter  in  diameter.  This  erosion  is  usually  not  sur- 
rounded by  any  discoloration,  and  is  difficult  to  locate  with  the 
naked  eye. 

Poikilocytosis  and  polychromatophilia  are  present  typically  in 
the  severe  cases.  One  of  the  most  remarkable  features  of  hook- 
worm disease  is  the  utter  lack  of  agreement  between  the  severity 
of  symptoms  and  lesions,  including  the  blood  changes,  and  the 
number  of  worms  found  in  the  intestine  (Evans4).  In  some  of 
the  most  severe  cases  a  decided  leukopenia  rather  than  leukocytosis 
is  present.     In  the  differential  count  of  white  cells,  apparently 

1  Zeitschrift  fur  klinische  Medizin,  1906,  Band  lviii. 

2  Ankylostoma  Infection,  Lancet,  March  18,  1911,  p.  717. 

3  Hookworm  Disease,  Journal  of  the  American  Medical  Association,  May  28,  1910, 
p.  1765. 

4  Pathology  of  Uncinariasis,  Journal  of  the  American  Medical  Association,  January 
29,  1910,  p.  394. 


ANKYWSTOMA   DUODEN ALE— HOOKWORM  811 

the  only  important  abnormality  is  in  the  number  of  eosinophils. 
Eosinophilia  is  an  almost  constant  finding,  and  practically  all 
observers  are  agreed  that  the  degree  of  eosinophilia  is  not  an  index 
of  the  severity  or  extent  of  the  infection. 

Symptoms. — The  principal  effect  produced  by  these  parasites 
is  a  grave  disease  that  runs  its  course  under  the  picture  of  pernicious 
anemia,  accompanied  by  weakness  of  the  heart,  dizziness,  dyspnea, 
and  an  occasional  slight  fever.  Unless  the  worms  are  removed, 
the  poverty  of  the  blood  may  reach  such  a  stage  as  to  lead  to  a 
fatal  outcome.  It  is  as  yet  undetermined  whether  the  anemia  is 
caused  by  loss  of  blood  or  by  hemolytic  substances  derived  from 
the  parasites. 

Besides  the  anemia  and  its  concurrent  symptoms,  there  are  gastric 
disturbances,  pyrosis,  abdominal  pains,  nausea  and  sometimes  vom- 
iting. In  the  feces  occult  blood  is  always  found,  and  often  the 
Charcot-Leyden  crystals.  Not  ever}7  host  of  this  parasite  is  neces- 
sarily sick;  examinations  of  a  large  number  indicate  that  the  great 
majority  do  not  exhibit  any  symptoms  of  the  disease. 

On  the  other  hand,  Stiles1  found  that  if  the  patient  is  infected 
before  puberty  his  physical  and  mental  development  is  retarded 
and  he  shows  a  more  or  less  extreme  anemia.  A  person  twenty-one 
years  of  age  may  appear  not  better  developed  than  one  fourteen  to 
eighteen  years  old.  The  skin  is  dry,  and  there  is  a  noticeable 
absence  of  perspiration.  The  color  may  be  waxy  white  to  dirty 
yellow;  it  has  a  resemblance  to  tallow.  The  hair  of  the  head  is 
dry,  reminding  one  of  hemp.  The  beard  and  the  axillary  and 
pubic  hair  may  be  very  late  and  scant  of  growth.  Edema  may  be 
present  in  the  face,  feet,  legs,  scrotum,  or  entire  body;  it  seems 
to  be  especially  common  over  the  cheek  bones.  Skin  wounds 
are  likely  to  be  rather  slow  in  healing.  Many  of  the  patients 
(about  57  per  cent,  of  the  well  marked  ones)  either  show7  tibial 
ulcers  or  give  a  history  of  such  lesions.  The  face  is  likely  to  have 
an  anxious,  ofttimes  stupid  expression.  Dark  lines  under  the  eyes 
are  common.  The  visible  mucous  membranes  may  be  chalky 
white.  The  pupils  show  a  tendency  to  dilatation,  even  wdien  facing 
a  strong  light;  many  patients  exhibit  a  peculiar  blank  stare;  night- 
blindness  is  reported  in  a  number  of  instances.  Cervical  pulsation 
may  be  very  prominent,  and  is  frequently  visible  six  to  twelve 
feet  distant.  The  thorax  may  be  so  emaciated  that  the  ribs  stand 
out  very  prominently.  The  shoulders  droop  and  are  thrown 
forward;  the  shoulder  blades  stand  out  prominently  (winged 
shoulder  blades) .  In  many  instances  the  abdomen  is  so  protuberant 
as  to  remind  one  of  pregnancy.  This  condition  is  known  locally  as 
"pot-belly,"  "buttermilk-belly,"  or  "shad-belly." 

Diagnosis. — There  is  probably  no  disease  known  to  the  medical 
profession  which  is  more  "easily  diagnosed  and  more  easily  treated 

1  Hookworm  Disease,  Public  Health  Bulletin,  No.  32. 


812  ANIMAL  PARASITES  OF   THE  INTESTINE 

than  hookworm  disease.  In  the  diagnosis  the  color  of  the  stools 
may  be  suggestive,  as  hookworm  patients  pass  reddish-brown 
stools.  The  following  simple  test  may  be  made:  Several  ounces 
of  the  stool  are  wrapped  in  white  paper  and  allowed  to  stand  for 
a  few  hours.  In  severe  and  in  some  moderately  light  cases  a 
distinct  reddish-brown  stain  will  be  found  on  the  paper.  It  is 
rare  that  the  adult  worms  are  seen  in  the  discharges  except  during 
treatment,  but  the  stools  of  hookworm  cases  contain  the  character- 
istic eggs  of  the  parasite,  and  by  finding  these  eggs  under  the 
microscope  a  positive  diagnosis  can  easily  be  made. 

Treatment. — Ground  itch  in  the  papular  or  vesicular  stage  may 
be  treated  with  5-per-cent.  salicylic  acid  suspended  in  collodion. 
This  usually  limits  the  attack  to  one  or  two  days.  During  the 
pustular  stage  the  wound  should  be  cleansed  and  cauterized  with 
silver  nitrate,  and  then  a  dry  dressing  of  zinc  oxide  ointment  applied 
twice  daily.  To  allay  itching  and  prevent  secondary  infection  a  com- 
bination 5-per-cent.  zinc  oxide  and  salicylic  acid  ointment  applied 
locally,  twice  daily,  is  recommended.  It  is  important  to  keep  the 
affected  foot  bandaged  or  covered  to  prevent  scratching  or  rubbing. 

To  expel  the  worms  after  a  preparatory  treatment  with  purgatives, 
thymol  gives  the  best  results.  It  is  more  effective  when  mixed  with 
an  equal  quantity  of  sodium  bicarbonate;  its  value  is  enhanced  and 
the  unpleasant  stomach  symptoms  relieved.  Magnesium  sulphate 
is  first  given,  to  remove  the  mucus  and  feces  surrounding  the  hook- 
worms. The  night  before  the  initiatory  treatment,  15  Gm.  (^ 
ounce)  of  magnesium  sulphate  is  to  be  taken  in  two  or  three  doses 
at  intervals  of  one  hour;  the  next  morning  two  doses  of  thymol, 
in  capsules,  two  hours  apart;  two  hours  later,  15  Gm.  (|  ounce) 
of  magnesium  sulphate.  Never  give  castor  oil.  Oils  of  all  kinds, 
fats  and  alcohol  favor  the  absorption  of  the  thymol,  with  toxic 
effect.  The  dose  of  thymol  should  be  adapted  to  the  age  of  the 
patient,  as  follows:  Under  five  years,  0.5  Gm.  (7|  grains);  five  to 
ten  years,  1  Gm.  (15  grains);  ten  to  fifteen  years,  2  Gm.  (30  grains); 
fifteen  to  twenty  years,  3  Gm.  (45  grains);  twenty  to  sixty  years, 
4  Gm.  (60  grains) ;  over  sixty  years,  3  Gm.  (45  grains).  The  patient 
should  lie  on  his  right  side,  which  assists  the  thymol  in  entering 
the  duodenum.  No  food  or  liquid  is  allowed  until  after  the  last 
dose  of  magnesium  sulphate  has  worked  off  thoroughly.  This 
treatment  should  be  repeated  once  a  week  until  microscopic  exami- 
nation shows  that  the  ova  are  absent  from  the  feces.  Another 
way  to  check  up  the  results  of  the  treatment  is  to  instruct  the 
patient  to  wash  his  stools  for  three  days  through  a  cheesecloth, 
keeping  the  cloth  constantly  moist.  The  fecal  matter  washes 
through,  and  the  worms  are  found  in  the  cheesecloth.  The  treat- 
ment is  to  be  continued  as  long  as  the  worms  are  found. 

Should  thymol  fail  to  effect  a  complete  CUre,  or  should  the  patient 
seriously  object  to  it  on  account  of  the  burning  sensation  that 
attends  its  administration,  oil  of  chenopodium  (American  wormseed) 


ANKYLOSTOMA    DUODENALE    HOOKWORM  813 

may  be  prescribed.  It  is  highly  recommended  by  Oriental  physi- 
cians who  have  had  extended  experience  with  it.  After  the  patient 
has  fasted  for  eight  hours,  30  (mil  (1  ounce)  of  magnesium  sulphate 
is  to  he  given.  'Two  hours  later  1  Cc.  ( L5  minims)  of  oil  of  cheno- 
podium  is  administered  on  sugar,  and  repeated  every  two  hours  for 
three  doses.  The  last  dose  is  to  be  combined  with  30  (  V.  (1  ounce) 
of  castor  oil  and  3  Cc.  (45  minims)  of  chloroform.  The  treatment 
is  to  he  repeated  at  intervals  of  one  week  until  no  more  ova  are  found 
in  the  feces.     Smaller  doses  are  advocated  for  children. 

The  duodenal  tube  is  used  for  introducing  the  vermifuge  directly 
into  the  intestine  (see  Chapter  III).  Instead  of  34  per  cent,  of 
cures,  as  in  the  case  of  a  first  mouth  treatment,  Kantor1  reports 
that  fully  SO  per  cent,  are  cured  by  the  first  tube  treatment.  Only 
one  repetition  is  necessary  for  full  relief  in  the  great  majority  of 
cases.  Three  cubic  centimeters  (45  minims)  of  the  oil  of  cheno- 
podium  are  injected  with  a  glass  syringe.  Ten  minutes  later,  100 
Cc.  (3  ounces)  of  a  saturated  solution  of  magnesium  sulphate  is 
introduced  through  the  tube  into  the  intestine  by  gravity.  The 
flush  removes  the  drug  quickly  from  the  small  intestine  and  prevents 
undue  toxic  effects.  The  patients  have  a  copious  watery  movement 
of  the  bowel  in  a  half-hour  which  contains  the  oil  and  worms. 

Oil  of  eucalyptus  is  preferred  by  some  authors.  It  can  be  com- 
bined with  castor  oil  and  chloroform. 

Gm.  or  Cc. 

J^—Olei  eucalypti 3|0  lllxlv 

Chloroformi 2|0  TTlxxx 

Oleiricini 30J0  gj 

Misce. 

Sig. — To  be  taken  on  arising  in  the  morning,  every  other  day  for  ten  days. 

One  course  of  treatment  frequently  proves  effectual.  Should  ova 
be  found  in  the  feces,  another  ten  days'  treatment  will  be  required. 

The  oleoresin  of  male  fern  is  employed  either  in  a  single  portion 
of  8  Gm.  (5ij)  or  in  doses  of  4  Gm.  (5  j)  each  on  successive  days. 
Castor  oil  or  calomel  is  given  three  hours  after  the  administration  of 
the  anthelmintic.     Filmaron  may  also  be  employed. 

After  the  expulsion  of  the  worms  it  is  well  to  administer  iron 
to  hasten  the  recovery  from  the  anemia.  Pilula?  ferri  carbonas 
(Blaud)  0.3  Gm.  (5  grains)  may  be  administered  three  times  a 
day.  The  tincture  of  iron  chlorid  may  be  given  diluted  in  water 
in  doses  of  0.3  to  0.6  Cc.  (5  to  10  minims)  after  meals.  The  hypo- 
dermic administration  of  the  sterilized  solution  of  citrate  of  iron, 
supplied  in  glass  ampoules,  is  often  found  a  valuable  aid  to  prompt 
recovery  (see  page  581). 

Worm-carriers  who  have  no  symptoms  of  illness  should  be  treated 
prophylactically.  During  epidemics  and  as  a  prophylactic  measure 
the  laborers  in  mines  should  be  instructed  as  to  how  the  infection 
is  brought  about,  compelled  to  practice  scrupulous  cleanliness,  and 
taught  to  disinfect  their  feces. 

1  John  L.  Kantor,  The  Cure  of  Hookworm  Infection,  American  Journal  of  the 
Medical  Sciences,  April,  1920. 


814 


ANIMAL  PARASITES  OF   THE  INTESTINE 


TRICHOCEPHALUS  DISPAR. 

This  worm,  also  called  whip  worm  (Fig.  139),  inhabits  the  cecum 
and  colon  of  man  and  may  penetrate  into  the  mucous  membrane, 


Fig.  139. — Trichocephalus  dispar.     a,  male;  b,  female.     (From  Mosler.) 


Fig.  140. — Trichocephalus  dispar.  A,  male;  B,  posterior  extremity  of  female; 
C,  ovum,  a,  head;  b,  cephalic  extremity  of  body  "with  esophagus;  c,  stomach;  d,  gut; 
e,  cloaca;  /,  seminal  canal;  g,  penis;  I,  bell-shaped  penile  sheath,  with  tip  of  penis;  m, 
gut  of  female;  n,  anus;  o,  uterus;  p,  vaginal  cleft.  Magnification,  10.  (After  Kuchen- 
meister  and  Zurn,  from  Ziegler.) 


abstracting  blood  therefrom.  The  ova  are  lemon-shaped  (Fig. 
140,  (J).  As  a  rule  the  worm  causes  few  subjective  symptoms; 
occasionally,  however,  it  gives  rise  to  severe  enteritis,  anemia, 
fever,  or  meningeal  manifestations.     The  prevalence  of  whip-worm 


A.\<;i  ILI.I  l..\    l.\  TESTIS' MIS 


8 1 5 


infection  in  a  locality  is,  to  a  certain  extent  at  least,  an  index  of 
the  intelligence  and  cleanliness  of  its  citizens.  The  parasites  are 
difficult  to  destroy,  on  account  of  the  fact  that  they  thrust  their 
attenuated  head  ends  through  folds  of  the  mucosa,  and  so  have  a 
very  good  hold  on  the  bowel.  In  addition  to  the  discovery  of 
these  worms  in  their  usual  habitat,  they  have  been  found  by  various 
authors  in  the  ileum,  the  vermiform  appendix,  and  the  peritoneal 
cavity. 

Treatment. — Tapeworm  remedies  have  been  used  successfully.  It 
may  become  necessary  to  use  enemata  containing  petroleum — 4  to 
15  Cc.  (5j~iy)  to  a  liter  (quart)  of  water,  frequently  repeated. 


Fig.  141. — Female  of  Anguillula  in- 
testinalis,  with  eggs  and  embryo.  (After 
Perroncito,  from  Ziegler.) 


Fig.  142. — Anguillula  intestinalis. 
(After  Braun,  from  Ziegler.) 


ANGUILLULA  INTESTINALIS  (STRONGYLOIDES  STERCORALS). 

Anguillula?  (worms  1  to  2  millimeters  in  length— Figs.  141  and 
142)  are  found  in  the  tropics  and  semitropical  countries,  frequently 
in  association  with  Ankylostoma  duodenale.     It  seems  to  have 


816  ANIMAL  PARASITES  OF   THE  INTESTINE 

been  conclusively  shown  that  "Anguillula  intestinalis"  and 
"  Strongyloides  stercoralis"  are  synonyms  for  the  same  parasite. 
The  cephalic  extremity  is  rounded,  and  pierced  by  the  mouth,  about 
which  there  are  three  or  four  papillae.  Next  to  the  mouth  there  is  a 
vestibule;  then  comes  the  esophagus,  which  contains  three  horny 
teeth.  Beyond  the  esophagus  the  intestine  extends  to  the  anus, 
which  is  situated  at  the  base  of  the  tail.  The  female  is  larger  than 
the  male  and  usually  more  numerous.  The  vulva  is  situated  on 
the  right  side  of  the  body,  a  little  below  the  middle,  and  leads  into 
a  double  uterus,  each  horn  of  which  ends  in  an  ovary.  The  male 
parasite  presents  two  cone-shaped  and  curved  spicules  at  the 
base  of  the  tail,  which  serve  as  the  copulatory  organ.  The  eggs 
are  small,  elliptical,  and  are  usually  segmented  when  laid.  There 
are  some  anatomic  differences  between  the  free-living  generation, 
the  parasitic  form,  and  the  larva?. 

Symptoms. — The  worms  may  be  present  without  symptoms,  or 
they  may  give  rise  to  serious  conditions,  in  particular  to  diarrhea, 
which  is  known  under  the  name  of  anguilluliasis. 

Treatment. — The  anthelmintics  mentioned  under  "Trichoceph- 
alus"  are  also  employed  here.  Recently  glycerin  has  been  recom- 
mended: 25  Gm.  (5vj)  of  pure  neutral  glycerin  by  mouth,  and 
immediately  afterward  another  25  Gm.  in  keratin  capsules  to 
retard  absorption;  again,  two  hours  later,  30  Gm.  (g  j)  per  rectum. 
This  treatment  is  to  be  given  twice  weekly.  Olive  oil  in  large 
doses  is  also  said  to  be  effectual. 

TREMATODES. 

Trematodes  (fluke  worms),  found  quite  often  in  the  lower  animals, 
are  comparatively  rare  in  man.  They  are  leaf-  or  tongue-shaped, 
with  an  apparatus  for  sucking.  A  few  isolated  cases  have  been 
reported  in  the  United  States,  but  the  subjects  were  foreigners. 
Trematodes  are  mostly  confined  to  Japan,  China,  Egypt,  Arabia,  and 
India.  The  worms  are  hermaphrodite.  There  are  several  varieties : 
Distoma  hepaticum  (Fig.  143),  Distoma  lanceolatum  (Fig.  144), 
Distoma  felinum,  Distoma  crassum,  Distoma  hematobium  (Bilhar- 
zia,  Fig.  146),  Distoma  heterophyes,  Distoma  conjunctum,  Distoma 
sinense,  and  some  others. 

Stiles  has  found  the  Distoma  hematobium  (Bilharzia)  but  twice 
in  the  United  States,  both  times  in  foreigners.  On  the  Isthmus  of 
Panama,  according  to  statistical  records  obtained  from  the  Chief 
Sanitary  Office,  Distoma  hematobium  has  been  reported  104  times. 
These  statistics  were  obtained  from  approximately  30,000  stool 
examinations.  The  worms  differ  from  most  trematodes  by  being 
two-sexed  instead  of  hermaphrodite.  They  have  a  white  appear- 
ance, are  pointed  at  each  end,  and  1  centimeter  (|  inch)  long.  They 
are  all  provided  with  suckers.    When  young  the  parasites  live 


r  /,-  i:\i.\to  i  )i-:s 


817 


apart;  but  after  maturing  the  female  enters  the  gynecophoric 
groove  <>r  canal  i>t'  the  mule  (Fig.  11")),  and  frequently  remains 
completely  hidden  there,  though  in  some  cases  it  protrudes,  on 
account  of  its  greater  length,  ;it  the  posterior  extremity. 

From  observations  made  by  Brayton1  it  appears  that  the  portal 
vein  is  the  principal  habitat  of  the  adult  parasite,  but  the  young 


Fig.    144. — Distoma    lanceolatum. 
(v.  Jaksch.) 


r- B 


A_ S| 


Fig.  143. — Distoma  hepaticum,  with 
male  and  female  genital  apparatus. 
(From  Ziegler,  after  Leuckart.) 


Fig.  145. — Distoma  hematobium  (Bil- 
harzia).     (Guiart.)     A,  male;  B,  female. 


worms  are  found  also  in  the  liver,  in  the  intestinal  veins,  in  the 
bladder  walls,  and  in  the  pelvic  bloodvessels  of  both  sexes.  In  the 
lungs  the  blocking  of  bloodvessels  with  the  ova  and   surrounding 


1  Bilharziasis  in  the  New  World,  Journal  of  the  American  Medical  Association, 
April  30,    1910,  p.   1437. 
52 


818  ANIMAL  PARASITES  OF  THE  INTESTINE 

infiltrations  gives  rise  to  deposits,  which  may  be  mistaken  for  tuber- 
culous deposits.  Cirrhosis  of  the  liver  and  biliary  calculi  may  be 
caused  by  the  presence  of  the  parasite.  Cystitis  and  urethritis 
are  common  complications,  and  often  the  parasite  is  the  starting- 
point  of  stone.  In  the  severer  cases  there  may  exist,  with  extension, 
the  entire  symptom-complex  of  "surgical  kidney"  or  "surgical 
bladder."  When  the  intestinal  tract  is  involved,  the  symptoms 
resemble  those  of  tropical  dysentery. 

Treatment. — From  the  above  it  would  seem  that  the  anthelmintics 
possess  little  value  in  the  treatment  of  this  disease.  The  treatment 
should  be  of  a  general  character,  to  mitigate  the  symptoms,  with 
special  attention  to  the  complications,  for  in  many  cases  the  disease 
is  self-limited.  Arsphenamine  has  been  found  to  be  absolutely 
useless  and  should  not  be  employed. 

Emetin  intravenously,  at  intervals  of  two  or  three  days,  com- 
mencing with  0.02  Gm.  (§-  grain)  and  increasing  rapidly  to  0.0G 
Gm.  (1  grain),  has  produced  striking  results.  Ten  to  fifteen  injec- 
tions usually  answer  the  purpose.  This  treatment  is  applicable  to 
cases  without  infectious  complications  (see  page  723). 

The  intravenous  injection  of  antimony  and  sodium  tartrate  is 
now  assumed  to  be  a  specific  for  bilharziasis.  This  drug  also  destroys 
the  worms  in  the  portal  circulation.  Both  the  subjective  and  the 
objective  symptoms  are  immediately  improved.  Since  the  remedy 
is  a  powerful  toxic  drug,  it  must  be  used  with  great  caution.  During 
the  first  two  weeks  of  treatment  0.03  Gm.  (§  grain)  is  given  intra- 
venously every  other  day,  and  the  dose  is  gradually  increased  until 
0.12  Gm.  (2  grains)  is  given  at  one  injection.  This  amount  can  then 
be  continued  every  three  to  five  days  until  a  maximum  of  2  Gm. 
(30  grains)  has  been  taken  for  the  course. 

Colloidal  antimony  sulphide  intravenously  is  less  toxic,  and  is  said 
by  some  authors  to  be  equally  efficient  in  ridding  the  body  of  the 
infecting  parasites.  Rogers  employed  both  the  sodium-antimony 
tartrate  and  colloidal  antimony  sulphide,  but  found  the  latter  to  be 
entirely  without  evident  benefit. 

TRICHINA  SPIRALIS. 

Trichina  spiralis  belongs  to  the  nematodes.  The  females  are  about 
twice  the  size  of  the  males,  which  are  3  to  4  millimeters  (about 
§  inch)  long  (Fig.  146).  The  parasite  is  usually  taken  into  the 
stomach  with  uncooked  pork,  sausage,  ham,  or  bacon.  The 
envelope  holding  the  embryo  opens  within  three  or  four  hours, 
liberating  its  contents.  Fructification  of  the  young  parasites  takes 
place  in  thirty  to  forty  hours.  The  development  of  the  trichinae 
in  the  intestine  and  the  production  of  a  new  generation  take  place 
within  one  or  two  weeks.  The  young  parasites  are  able  to  migrate 
into  the  muscles  of  the  host  and  further  develop  (Fig.  147).    The 


Tint  U1S A    SPIRALIS 


819 


appearance  of  the  symptoms  corresponds  to  the  time  consumed 
in  tlic  development  of  the  trichinae  and  their  penetration  into  the 
muscles.    This  disease  is  called  trichinosis. 

The  symptoms  are:  loss  of  appetite,  malaise,  headache,  fever, 
nausea  or  vomiting,  diarrhea,  tenderness  of  the  epigastrium,  cramps 
in  the  abdomen  and  limbs,  great  prostration,  swelling  and  soreness 
of  the  muscles  and  indisposition  to  move  them,  increased  rapidity 
of  respiration,  swelling  of  the  eyelids  and  feet  and  sometimes  of  the 
knees,  elbows,  and  ankles. 


Fig.  146. — Trichina  spiralis. 
X,  female;  F,  male,  a,  anus;  b, 
mouth;  c,  body  cells;  c,  embryo 
escaped  from  vulva;  i,  intestine; 
o,  ovary;  p,  copulative  papilla?;  t, 
testicles;  u,  uterus;  v,  seminal  ves- 
icles. Magnification,  80.  E,  em- 
bryo greatly  enlarged.      (Guiart.) 


Fig.    147. — Live    migrating    trichina?    in    the 
muscles  of  man  (enlarged).      (Rosenheim.) 


The  number  of  eosinophilic  leukocytes  in  normal  blood  is  2  to  4 
per  cent,  of  the  total  leukocytic  count,  whereas  in  trichinosis  the 
proportion  may  reach  40  to  50  per  cent,  after  the  fourteenth  day. 
Eosinophilia  must  be  taken  in  connection  with  other  indications, 
since  it  is  present  in  a  variety  of  intestinal  parasitic  affections,  in 
eczema  and  other  cutaneous  affections,  in  bronchial  asthmatic  con- 
ditions, and  in  typhoid  fever. 

The  trichinae  can  rarely  be  found  in  the  feces  or  blood  of  the 
patient.  The  best  test  is  made  by  examination  of  the  muscle. 
There  is  an  instrument  made  especially  for  the  purpose  of  removing 


820  ANIMAL  PARASITES  OF   THE  INTESTINE 

fragments  of  muscle  tissue  for  examination.  The  trichinae  in 
the  muscles  become  encapsulated  and  may  undergo  calcareous 
degeneration,  followed  by  fatty  degeneration,  when  recovery  takes 
place.    The  disease  is  often  fatal. 

Treatment. — In  the  treatment  it  is  advisable  to  thoroughly 
evacuate  the  bowels  to  remove  the  parasites  which  are  still  there. 
A  dose  of  calomel,  0.3  Gm.  (5  grains),  should  be  given,  followed  in 
four  hours  by  15  Gm.  (5ss)  of  magnesium  sulphate.  This  can  be 
repeated  daily  for  four  or  five  days  to  eliminate  all  the  embryos. 
Thymol,  0.1  Gm.  (2  grains),  can  be  given  as  an  anthelmintic  and 
antiseptic  four  times  during  the  twenty-four  hours.  Male  fern 
or  santonin  may  be  administered  if  pi ef erred.  Glycerin  has  been 
prescribed  to  kill  the  worms  by  its  hygroscopic  properties;  it  may 
be  taken  in  tablespoonful  doses  three  times  daily,  well  diluted. 
Large  doses  of  quinin  have  been  recommended.  Picric  acid  has 
also  been  used. 

A  study  of  trichinosis  in  which  beneficial  results  were  attained  in 
man  by  the  use  of  serum  from  patients  recovered  from  the  disease 
has  been  published.  In  two  patients  in  the  active  stages  of  trich- 
inosis the  administration  of  the  serum  showed  remarkable  curative 
power.  Serum  from  experimental  animals,  however,  convalescent 
from  trichinosis,  when  injected  into  other  animals  or  fed  to  them 
with  trichinous  meat,  does  not  inhibit  the  customary  development 
of  trichinae,  but  such  serum  is  of  decided  value  in  combating  the 
toxic  features  of  trichinosis. 

MYIASIS  INTESTINALIS. 

The  larvae  of  many  different  species  of  flies  may  live  and  possibly 
multiply  in  the  intestinal  canal,  causing  at  times  grave  lesions, 
ulcerations,  perforation,  and  thickening  of  the  wall  of  the  intestine, 
with  resulting  stenosis.  The  treatment  should  aim  at  the  early 
destruction  and  expulsion  of  the  parasites. 


CHAPTER    Lit  I. 

DISEASES  OE  THE  RECTUM. 

Hemorrhoids;  Tumors  of  the  Rectum;  Strictures  of  the 
Rectum;  Proctitis;  Ulcers  of  the  Rectum;  Prolapse  of 
the  Rectum;  Proctospasm;  Paresis;  Coccygodynia. 

HEMORRHOIDS. 

Hemorrhoids,  or  piles,  are  either  diffuse  or  circumscribed  dila- 
tations of  the  hemorrhoidal  veins.  The  tumors  or  swellings  are 
situated  subcutaneously  in  the  external  anal  sphincter  and  sub- 
mucously  in  the  lowest  portion  of  the  rectum.  There  is  often 
inflammatory  infiltration  and  connective-tissue  proliferation.  Ac- 
cording to  the  veins  affected,  a  distinction  is  made  between  external 
and  internal  hemorrhoids. 

External  hemorrhoids  are  situated  at  the  anal  margin  and  quite 
outside  the  rectum,  while  internal  hemorrhoids  are  situated  entirely 
inside  the  rectum  and  originate  from  the  bowel  proper.  The 
distinction  between  an  external  and  an  internal  hemorrhoid  is  not 
explained  by  the  simple  fact  that  one  is  below  and  the  other  above 
the  external  sphincter.  A  different  set  of  bloodvessels  is  implicated 
in  each  case.  An  external  hemorrhoid  is  a  varicosity  of  an  external 
hemorrhoidal  vein,  and  is  therefore  an  affection  of  the  general  venous 
circulation.  An  internal  hemorrhoid  is  a  varicosity  of  the  middle 
or  the  internal  hemorrhoidal  vein,  both  of  which  are  parts  of  the 
visceral  venous  system.  A  glance  at  the  venous  anatomy  of  the 
rectum  and  the  anus  will  show  the  arrangement  of  these  two  sets 
of  veins,  and  will  also  explain  how,  from  the  free  anastomosis  which 
exists  between  them,  it  is  improbable  that  one  should  be  affected 
without  influencing  the  other  to  a  greater  or  less  extent. 

Hemorrhoids  develop  when  the  flow  of  blood  from  the  hemor- 
rhoidal veins  toward  the  vena  cava  and  the  portal  vein  is  obstructed. 
The  cause  of  the  interference  may  be  situated  in  the  rectum  or  in 
some  other  part  of  the  large  intestine.  Here,  no  doubt,  chronic 
constipation  and  the  excessive  use  of  purgatives  play  an  important 
part.  Sedentary  habits,  so  often  supposed  to  be  the  cause,  probably 
act  more  indirectly  than  directly — by  inducing  constipation.  The 
upright  position  of  man  and  the  absence  of  valves  in  the  superior 
mesenteric  vein  are  predisposing  causes  of  a  mechanical  character. 
Furthermore,  attention  should  be  given  to  strictures,  tumors  and 
foreign  bodies  in  the  rectum.     Hemorrhoids  also  make  their  appear- 


822  DISEASES  OF  THE  RECTUM 

ance  in  cases  of  chronic  colitis  and  of  malignant  tumors  of  the  large 
intestine,  especially  of  the  sigmoid  flexure.  The  etiology  includes 
also  affections  of  neighboring  organs — Madder,  prostate,  uterus; 
pregnancy,  if  it  interferes  with  the  free  flow  of  venous  blood  by 
pressure,  may  be  a  causative  factor.  It  has  not  been  conclusively 
proved  whether  disturbances  in  the  circulation  in  connection  with 
heart  disease  may  lead  directly  to  the  formation  of  hemorrhoids. 

Hemorrhoids  may  occur  in  young  persons,  but  the  subjects  are, 
as  a  rule,  persons  of  more  mature  years.  The  male  sex  is  decidedly 
predisposed. 

Anatomically,  hemorrhoids  show  themselves  either  as  a  diffused 
tumor  surrounding  the  anus  beneath  the  skin  and  the  mucous 
membrane,  or  as  circumscribed  tumors,  single  or  multiple,  of  vary- 
ing size. 

Symptoms. — Hemorrhoids  usually  give  rise  to  local  symptoms. 
In  some  cases,  however,  large  tumors  exist  without  inducing  any 
subjective  discomforts.  The  local  manifestations  include  a  feeling 
of  pressure,  weight  in  the  rectum,  itching,  tenesmus,  burning  and 
painful  sensations  in  the  anus.  These  symptoms  are  most  strik- 
ingly in  evidence  when  the  tumors  become  irritated  by  inflamma- 
tion. Hemorrhages  are  of  frequent  occurrence,  and  may  be  the 
first  symptom  to  send  the  patient  to  the  doctor.  The  symptoms 
are  usually  less  after  an  evacuation  of  the  bowels;  hemorrhage 
also  has  a  temporarily  relieving  effect — evidently  because,  of  the 
abstraction  of  blood  from  the  hyperemic  and  inflamed  tissues. 
The  hemorrhages  are  not  really  beneficial,  however,  as  was  formerly 
supposed,  and  as  is  held  even  today,  especially  by  the  laity.  The 
symptoms  mentioned  above,  particularly  the  pains,  may  occasionally 
become  so  excruciating  that  the  patients  contemplate  suicide.  The 
complications  of  hemorrhoids  are :  catarrhal  conditions  of  the  rectum 
with  excessive  secretion  of  mucus,  inflammations,  excoriations  and 
fissures  of  the  hemorrhoidal  nodes.  These  may  give  rise  to  infections 
and  induce  abscesses,  fistulse,  and  phlegmonous  processes.  The 
incarceration  of  prolapsed  hemorrhoids  is  very  painful.  When  it  is 
impossible  to  reduce  large-sized  prolapsed  nodules,  they  may  become 
greatly  swollen  and  then  cause  the  most  violent  pains  (strangu- 
lation). Grave  anemia  may  develop  in  consequence  of  chronic 
hemorrhages. 

General  symptoms  caused  by  hemorrhoids  include  a  feeling  of 
pressure  and  fulness  in  the  abdomen,  sacral  and  dorsal  pains,  and 
nervous  phenomena  such  as  pressure  in  the  head,  headache,  vertigo, 
and  nausea.  These  symptoms  depend  upon  differences  in  the 
relative  blood-pressure  in  the  territories  drained  by  the  vena  cava 
and  the  portal  vein,  chronic  constipation,  toxemia,  and  neurasthenia. 

Treatment. — In  the  treatment  of  hemorrhoids  the  etiology  must 
be  taken  into  consideration;  in  fact  we  should  always  endeavor  to 
remove  the  cause.     Particular  attention  must  be  given  to  the  relief 


iii:\i<>h'h'iioii>s  si>:j 

01   the  chronic  constipation   which   is  the   most    frequenl    cause   of 

hemorrhoids  (see  Chapter  WWII  on  Chronic  Constipation). 
With  respect  to  diet,  a  distinction  is  to  be  made  in  the  treatment 
between  hemorrhoids  with  and  those  without  hemorrhage.  A 
careful  regulation  of  the  diet  is  obligatory  in  cases  which  are  char- 
acterized by  severe  continuous  or  periodical  hemorrhages;  alcoholic 
beverages,  sharp  spices  and  highly  seasoned  food  or  drink  are  to 
be  avoided,  and  the  patients  must  abstain  from  prolonged  walking, 
climbing,  horseback  riding,  golf,  sports,  wheeling,  and  all  fatiguing 
occupations.  When  the  hemorrhages  are  insignificant  or  absent, 
a  diet  similar  to  that  advised  in  chronic  constipation  is  to  be  main- 
tained (see  Chapter  Ml  on  Diet).  An  invigorating  purgative  diet, 
not  too  abundant  in  refuse  material,  is  appropriate  in  such  cases. 

Mineral  water  drinking  cures  often  produce  good  effects.  The 
sodium  chlorid  waters  are  more  suitable  for  lean  persons,  while  the 
sodium  sulphate  and  the  magnesium  sulphate  waters  are  more 
particularly  adapted  to  adipose  patients  with  a  certain  plethoric 
habit.  The  good  effect  frequently  seen  after  taking  these  waters 
is  explained  by  their  purgative  action.  The  other  favorable  factors 
at  a  health  resort,  such  as  bodily  and  mental  rest,  proper  diet, 
frequent  baths,  and  sports,  must  get  some  credit  for  the  benefit. 
Unfortunately  the  good  results  of  the  cure  are  often  transitory, 
disappearing  when  the  patients  return  to  their  homes.  In  a  good 
many  cases,  however,  an  annually  repeated  course  of  treatment  with 
such  waters  is  capable  of  effecting  a  permanent  cure  (see  page  252). 

In  every  case  of  hemorrhoids  the  patients  are  to  be  instructed 
to  pay  scrupulous  attention  to  the  cleansing  of  the  anus.  In  the 
case  of  many  patients  with  hemorrhoids  and  a  sensitive  anus,  it  is 
not  sufficient  that  the  anus  be  cleaned  after  defecation  with  toilet 
paper  alone;  it  should  be  washed  with  warm  water  held  in  a  piece 
of  absorbent  cotton,  carefully  dried,  then  bathed  in  an  antiseptic 
fluid  (cold  3-per-cent.  boric  solution)  or  an  astringent  solution  (one 
teaspoonf ul  of  tannic  acid  to  one  pint  of  water) .  After  this  treat- 
ment the  anus  and  the  immediate  vicinity,  especially  the  tumors, 
should  be  coated  with  a  thin  layer  of  petrolatum. 

The  treatment  of  hemorrhage  is  of  the  greatest  importance. 
Severe  acute  hemorrhage  requires  tamponing  of  the  rectum.  In 
this  work  the  proctoscope  (Fig.  37)  is  a  valuable  aid.  When  the 
hemorrhages  are  profuse,  hot  irrigations  of  water  (95°  to  115°  F.) 
act  effectively.  If  necessary,  1-  to  2-per-cent.  tannic  acid  may  be 
added.  Good  styptic  effects  are  also  attributed  to  a  10-per-cent. 
solution  of  gelatin  in  water.  A  similar  effect  is  produced  by  the 
application  of  wads  of  cotton  saturated  in  epinephrin  solution 
(1:1000);  the  epinephrin  contracts  the  bloodvessels  markedly. 
"When  the  seat  of  the  hemorrhage  is  high  up,  suppositories  containing 
astringents  may  be  introduced  as  far  as  possible.  Boas  recommends 
a  10-per-cent.  solution  of  chemically  pure  chlorid  of  line;  20  Cc. 


824 


DISEASES  OF   THE  RECTI M 


Fig.  148.— Pj-ramidal 
form  ice-bag. 


(5v)  is  injected  into  the  rectum  by  means  of  a  small  syringe  twice 
daily.     I  have  used  ten  drops  of  the  fluidextractum  thuja  in  a  tea- 
spoonful  of  water  to  be  injected  beyond  the  sphincter,  morning  and 
night,  by  means  of  a  small  glass  syringe, 
with  benefit. 

Should  the  hemorrhage  not  be  arrested 
by  means  of  these  drugs,  anesthesia  should 
be  induced  and  the  bleeding  points  found 
and  ligated  or  cauterized.  Quinin  and  urea 
hydrochlorid  in  1-per-cent.  solution  is  a  very 
efficient  local  anesthetic  and  has  been  suc- 
cessfully employed  in  a  great  variety  of 
operations  upon  the  rectum.  It  is  marketed 
in  hermetically  sealed  glass  ampoules. 

For  chronic  slow  hemorrhage,  which  may 
in  time  lead  to  grave  anemia,  the  adminis- 
tration of  hamamelis  by  mouth  may  be  rec- 
ommended.    Of  the   fluidextractum  ham- 
amelis virginianse,  one  teaspoonful  is  given 
three  times  a  day,  and  this  medication  is  con- 
tinued for  months;  it  is  harmless  and  causes 
no    discomfort.       Ergotin     and    hydrastis 
canadensis  are  much  less  efficacious  (see  page  514).     An  ointment 
of  the  following  composition  may  be  applied  directly  to  the  hemor- 
rhoidal tumors: 

Gm.  or  Cc. 

]$ — Extracti  hamamelidis  virginianse        .       013  gr.  v 

Olei  theobromatis 10 10  5iiss 

Olei  anrygdalse 7|5  3ij 

Misce  et  ft.  unguentum. 

Sig. — Apply. 

The  pains,  which  frequently  cause  great  annoyance  when  the 
hemorrhoids  are  inflamed  and  bleeding,  are  best  treated  with  rest 
in  bed  and  cold  applications.  Zweig  has  constructed  a  special 
ice-bag  of  pyramidal  form  (Fig.  148)  which,  when  filled  with  ice, 
is  to  be  placed  between  the  gluteal  eminences  and  brought  in 
direct  contact  with  the  painful  parts;  it  is  retained  in  position  by  a 
T-bandage  loosely  fastened.  For  relief  of  the  pains,  the  following 
may  be  applied  locally  in  the  form  of  suppositories  or  ointments: 
cocain,  eucain,  morphin,  opium,  epinephrin,  extract  of  belladonna, 
eumydrin,  anesthesin,  orthoform. 

Gm.  or  Cc. 

1$ — Anesthesini  (or  orthoform)      ...       0 1 2  gr.  iij 

Olei  theobromatis 2[0  3ss 

Misce  et  ft.  suppos.  no.  i. 


1$ — Anesthesini  (or  orthoform) 
Adipis  lanse  hydrosi, 
Petrolati 

Misce  et  ft.  unguentum. 


Gm.  or  Cc. 


.       0 

aa       4 


gr.  vnss 


HMMOURUOlM 


825 


Suppositories  of  chrysarobin  are  recommended  for  their  analgesic 
and  styptic  effects: 


1\ — Chrysarobini () 

Iodoformi 0 

Extracti  belladonna* 0 

Olei  theobromatis 2 

Misce  et  ft.  suppos.  no.  i. 

Sig. — One  suppository  two  or  three  times  daily. 


ir  Cc 
08 

02 

()1 
0 


Gin.  hi  ( v 


II 


Chrysarobini 

Iodoformi 

Extracti  belladonna? 

Petrolati 

Misce  et  ft.  unguentum. 

Sig. — For  external  hemorrhoids;  to  be  applied  several  times  daily. 


gr.  1:', 

gr.  | 
gr.  :, 
3ss 


gr.  ij 

gr.  ss 
gr.  x 
5ss 


1$ — Morphinae  sulphatis 0 

Extracti  belladonna? 0 

Extracti  hyoscyami 0 

Olei  theobromatis 1 

Misce  et  ft.  suppos.  no.  i. 

Sig. — Introduce  at  once,  and  repeat  in  two  hours  if  necessary 


Gm.  or  Cc. 

015 

01 
01 
0 


gr.  i 
gr.  I 
gr-  I 
gr.  xv 


Gm.  or  Cc. 

1$ — Cocainse  hvdrochloridi        ....       001  gr.  § 

Extracti  opii 0  03  gr.  ss 

Extracti  kramerise 0  5  gr.  vuss 

Olei  theobromatis 10  gr.  xv 

Misce  et  ft.  suppos.  no.  i. 

Sig. — Introduce  at  once,  and  repeat  in  two  hours  if  necessary. 

When  great  pain  is  experienced,  leeches  may  be  placed  at  some 
distance  from  the  anus.  Ulcerated  and  gangrenous  nodules  are 
to  be  covered  with  antiseptic  powders.  Occasionally  it  will  be 
necessary  to  reduce  prolapsed  nodules  which  have  become  incarcer- 
ated and  cause  severe  pain.  This  is  best  accomplished  with  the 
patient  in  the  lateral  posture  and  the  pelvis  elevated,  by  pressure 
with  a  lubricated  wad  of  gauze  and  by  gentle  force  with  the  ringers. 


Fig.  149. — Dumb-bell  pessary. 

To  minimize  the  pain  of  this  procedure,  first  apply  a  4-per-cent. 
solution  of  cocain,  or  leeches  to  reduce  the  congestion.  In  cases 
in  which  the  reduced  nodules  persist  in  prolapsing,  a  well  oiled 
dumb-bell  pessary  (Fig.  149)  may  be  introduced.  When  the 
prolapsed  nodules  are  gangrenous  they  should  not  be  replaced 
but  allowed  to  become  necrotic  and  fall  off,  analgesic  agents  being 
meanwhile  employed.     Esmarch's  rectal  truss  (Fig.  159,  page  817) 


826  DISEASES  OF  THE  RECTUM 

may  be  required  in  cases  of  very  large  non-inflammatory  hemor"- 
rhoidal  prolapse. 

Hemorrhoids  are  occasionally  treated  successfully  with  pessaries. 
The  object  is  to  counteract  the  dilatation  of  the  hemorrhoidal 
bloodvessels  by  means  of  persistent  and  constant  compression. 
The  pessaries  are  retained  for  one  hour  two  or  three  times  a  day, 
and  this  period  may  even  be  increased.  The  previously  mentioned 
dumb-bell  pessaries  are  the  ones  that  are  mostly  used.  They 
consist  of  two  ball-shaped  end  pieces  joined  by  either  a  straight 
or  a  bent  middle  piece.  One  of  the  balls,  after  being  well  oiled, 
is  introduced  into  the  anus  above  the  sphincter,  while  the  other 
lies  outside  the  anus — as  an  anchor.  Ratkowski  has  constructed 
a  pessary  of  a  somewhat  different  shape  (Fig.  150),  which  is  more 
useful  than  the  ordinary  dumb-bell  pessary.  It  consists  of  a 
button-shaped  part,  or  head,  which  is  inserted  into  the  anus,  and  a 
funnel-shaped  part,  which  is  joined  to  the  head  and  bulges  out  in  a 
downward  and  outward  direction.  The  head,  unlike  that  of  the 
dumb-bell  pessary,  is  small  and  flattened  in  its  vertical  diameter. 


Fig.  150. — Hemorrhoidal  funnel  pessary. 

Though  this  pessary  is  retained  more  securely  in  the  rectum,  the 
rectal  walls  and  the  prostate  gland  are  subjected  to  less  pressure  than 
with  the  dumb-bell  instrument.  The  stem  is  made  very  slender,  in 
order  to  avoid  irritation  of  the  sphincter,  while  the  conical  enlarge- 
ment exerts  considerably  more  lateral  pressure  than  can  be  accom- 
plished by  the  center  piece  of  the  dumb-bell  pessary.  The  anal 
muscle  and  mucous  membrane  are  thus  kept  under  the  continuous 
elastic  pressure  of  two  inclined  planes.  The  lower  end  is  large, 
in  order  to  prevent  the  passage  of  the  pessary  into  the  rectum. 
The  appliance  does  not  interfere  with  sitting  down,  which  is  fre- 
quently impossible  with  the  dumb-bell  pessary.  The  base  of  the 
cone  is  not  circular,  but  ovally  elongated,  and  therefore  fits  more 
snugly  into  the  anal  cleft.  This  instrument  is  made  of  light 
non-oxidizable  metal,  and  is  called  the  funnel  pessary.  It  can 
be  easily  cleansed.  It  compresses  the  dilated  vessels  sufficiently, 
sustains  the  prolapsed  nodules,  stimulates  the  tonus  of  the  relaxed 
sphincter,  and  strengthens  the  skin  and  mucous  membrane.  The 
pessary  is  to  be  worn  as  often  and  as  long  as  the  patient  can  stand 
it,  best  of  all  at  night. 


iikwioui.'iioms  82* 

The  ideal  treatment  for  hemorrhoids  is  the  entire  removal  of  the 
tumors.  This  is  accomplished  by  a  number  of  surgical  methods. 
Of  the  bloodless  methods,  stretching  of  the  sphincter,  which  is  the 
method  commonly  practiced  in  France,  should  be  mentioned  first. 

Verneuil,  a  French  surgeon,  first  introduced  this  method  of 
treatment  in  1874.  lie  was  consulted  by  a  distinguished  gentleman 
who  had  for  fourteen  years  suffered  from  anal  pains  supposed  to  be 
caused  by  fissure,  but  which  were  in  reality  caused  by  internal 
hemorrhoids  that  had  become  prolapsed  and  irreducible.  In  this 
condition,  not  only  had  the  patient's  pains  redoubled,  but  he  suffered 
great  loss  of  blood  so  that  he  was  near  to  death.  His  anemia  was 
so  profound  that  Verneuil  considered  the  usual  operative  methods 
too  dangerous  to  be  undertaken.  The  sphincters  were  very  much 
contracted  and  Verneuil  contented  himself  with  dilating  them. 
From  that  day  the  pain  and  loss  of  blood  ceased;  the  hemorrhoids 
were  cured  and  did  not  return.  Verneuil  hastened  to  put  this 
method  of  treatment  into  practice  in  other  cases,  with  most  excellent 
results.  The  sphincter  is  dilated  forcibly,  with  or  without  anes- 
thesia, either  by  means  of  the  speculum  or  by  the  introduction  of 
the  two  index  fingers.     Several  sessions  may  be  required. 

The  most  recent  bloodless  method  of  treatment  of  hemorrhoidal 
nodules  was  promulgated  by  Boas,  and  has  been  designated  by 
him  the  "  extra-anal  method  of  treatment  of  hemorrhoids."  Boas 
does  not  consider  it  proper  to  replace  the  prolapsed  nodules,  even 
when  there  is  much  pain;  on  the  contrary,  he  recommends  that 
they  be  left  outside,  and  even  that  others,  if  there  are  any  in  the 
rectum,  be  extruded  if  possible  and  kept  so.  The  patients  are 
requested  to  force  the  node  downward  as  far  as  possible  by  con- 
tinuous abdominal  pressure.  It  may  be  necessary  to  first  give  a 
rectal  injection  of  water  with  glycerin  or  of  normal  salt  solution. 
The  nodules  are  assisted  outside  by  manual  manipulations,  which 
usually  accomplish  the  purpose.  In  case  the  nodules  cannot  be 
easily  brought  out,  Boas  recommends  the  use  of  Bier's  suction  cup 
to  assist  in  the  prolapse.  It  is  necessary  to  obtain  complete  prolapse 
of  the  nodules  in  order  to  ensure  success  in  the  treatment.  The 
nodules,  after  prolapse,  become  dilated  and  completely  filled  with 
blood.  Simultaneously  the  anal  ring  becomes  edematous.  This 
edema  has  two  effects:  (1)  the  permanent  fixation  of  the  nodules 
outside  of  the  anal  ring;  (2)  the  gradual  cutting-off  of  the  circulation. 
The  edema  becomes  visibly  more  marked  during  the  first  three  or 
four  days.  The  edematous  ring  becomes  sensitive  to  pressure,  but 
later  the  edema  and  sensitiveness  slowly  diminish;  the  nodules 
become  gray,  undergo  shrinkage,  and  in  many  cases  show  upon 
their  surface  small  ulcerated  plaques.  Generally,  in  the  course  of 
about  eight  days  the  nodules  are  reduced  to  half  their  previous 
size  and  the  smaller  ones  may  have  disappeared  entirely;  and 
during  the  following  week  only  slightly  ulcerated  nodules  the  size 


828  DISEASES  OF  THE  RECTUM 

of  a  pea  are  to  be  seen,  which  gradually  become  progressively  paler, 
to  finally  disappear  altogether.  In  the  first  two  or  three  days  the 
patient  may  have  lancinating  pains,  which  can  be  relieved  by  the 
application  of  aluminum  acetate  solution  or  by  the  use  of  anodynes. 
Absolute  rest  in  bed  for  three  or  four  days  is  necessary.  The 
bowels  should  be  regulated  by  mild  aperients.  It  is  not  necessary 
to  maintain  any  particular  diet.  Boas  found  that  the  treatment 
usually  covered  eight  to  fourteen  days.  Ulcerated  nodules  should 
be  slightly  cauterized  with  silver  nitrate  or  dusted  with  antiseptic 
powders.  This  treatment  is  indicated  above  all  others  in  cases  in 
which  a  radical  operation  is  contra-indicated.  It  is  simple  and 
harmless. 

Midway  between  the  radical  and  the  bloodless  methods  stands 
the  injection  treatment  of  the  hemorrhoidal  tumors.  The  author's 
experience  with  injection  has  been  satisfactory  in  a  large  number 
of  cases,  but  the  method  requires  a  much  longer  time  than  surgical 
operation.  Frequently  the  subsequent  removal,  under  local  anesthe- 
sia, of  leaf-like  tags  is  necessary.  In  selected  cases  of  non-inflamed 
internal  hemorrhoids,  when  an  anesthetic  is  contra-indicated 
or  an  operation  is  refused,  the  injection  method  has  a  distinct 
field.  The  treatment  consists  in  injecting  the  nodules  with  small 
quantities  of  a  phenol-glycerin  solution.  For  this  purpose  the 
nodules  are  brought  before  the  anus.  The  anal  region  is  carefully 
cleansed,  the  rectum  is  washed  out,  and  subsequently  the  anus 
and  the  nodules  are  disinfected  with  a  0.5-per-cent.  solution  of 
lysol.  Each  nodule  is  then  injected  from  the  periphery,  by  means  of 
a  fine  hypodermic  needle  (Fig.  145),  drop  by  drop,  with  the  phenol- 
glycerin  solution,  until  the  main  portion  of  it  turns  whitish.  A 
fenestrated  rectal  speculum  (Fig.  152)  should  be  used.  If  possible 
the  tumors  are  replaced  in  the  rectum.  A  large  wad  of  cotton, 
applied  to  the  anus,  is  kept  in  place  by  a  T-bandage.  Rest  in 
bed  for  two  or  three  days  is  then  necessary,  with  a  diet  of  soups, 
and  opium  to  prevent  movement  of  the  bowels.  On  the  third 
day  castor  oil  is  given.  The  next  few  days  the  patient  remains 
inactive. 

The  injected  hemorrhoid  sloughs  off.  The  patient  does  not  know 
when  this  occurs,  and  in  normal  cases  the  spot  to  which  it  was 
attached  looks  healthy  and  clean.  Sometimes  a  raw  surface 
results,  but  this  soon  heals.  Should  an  ulcer  develop,  due  to  too 
large  an  injection  or  improper  technic,  no  harm  will  have  been 
done;  treatment  as  applied  to  any  ulcer  will  rapidly  heal  it. 

Never  inject  hemorrhoids  that  are  inflamed  or  irritated;  inject 
the  smaller  piles  first.  Handle  all  parts  with  extreme  gentleness. 
Apply  alcohol  to  protect  the  tissue  from  the  outflow  of  the  phenol 
solution.  Do  not  inject  the  second  time  until  all  inflammation 
and  soreness  has  disappeared. 

If,  upon  withdrawal  of  the  needle,  blood  follows,  there  has  not 


HEMORRHOIDS 


SL".I 


been  enough  of  the  solution  used;  reinsert  the  needle  and  inject 
more  and  allow  time  for  the  blood  to  coagulate.  When  pain  follows 
the  operation,  the  liberal  application  of  hot  water  will  relieve  it. 


Fig.  151. — Guarded  hypodermic  needle  for  injecting  hemorrhoids. 


Fig.  152. — Fenestrated  rectal  speculum. 


The  following  solution  may  be  used : 

Gm.  or  Cc. 

3— Phenolis 45  [0 

Glycerini 15  !0 

Misce. 

Sig. — Inject  one  or  more  minims. 


5iss 

oss 


Quinin  and  urea  hydrochlorid  in  5-per-cent.  solution  has  of  late 
been  used  with  marked  success.  The  solution,  injected  into  the 
hemorrhoid,  causes  fibrous  exudation  which  restricts  the  blood 
supply  of  the  part,  with  consequent  atrophy.  One  hemorrhoid 
can  be  injected  every  day  until  all  have  been  treated.  If  the 
hemorrhoids  are  strangulated  or  greatly  inflamed,  the  patient 
should  be  put  in  bed  for  a  few  days  and  local  applications  made 
until  the  inflammation  has  subsided,  when  the  injection  treatment 
is  begun.  The  technic  in  detail  as  employed  by  Dr.  Terrell  is  as 
follows:  The  hemorrhoids  are  brought  into  view  through  a  small 
conical  fenestrated  speculum.  The  hemorrhoid  selected  for  treat- 
ment is  swabbed  with  a  solution  of  equal  parts  of  iodin  and  alcohol. 
A  few  drops  of  a  5-per-cent  solution  of  quinin  and  urea  hydro- 


830  DISEASES  OF   THE  RECTUM 

chlorid  are  then  injected  very  slowly  into  the  pile  at  the  highest 
point  possible.  Just  sufficient  solution  is  injected  to  cause  slight 
distention,  a  very  small  needle  being  used — not  large  enough  to 
obstruct  the  view.  The  needle  should  be  inserted  into  the  body 
of  the  hemorrhoid  and  held  in  position  for  a  moment  after  the 


Fig.  153. — Hirschman's  anoscope  with  oblique  opening. 

injection  to  prevent  bleeding  at  the  point  of  puncture.  The  follow- 
ing day,  if  a  digital  examination  is  made,  the  hemorrhoid  will 
appear  thickened  and  indurated.  After  a  few  days  it  begins  to 
diminish  in  si\ze,  and  this  diminution  continues  for  ten  days  to  two 
weeks,  the  action  of  the  compound  seeming  to  be  continuous  for 
that  length  of  time.     At  the  end  of  the  period,  if  the  hemorrhoid 


HEMORRHOIDS  831 

still  persists,  the  treatment  should  be  repeated  as  before,-  with  a 
slightly  stronger  solution. 

I  find  that  the  Ilirschinan  anoscope  (Fig.  L53)  is  the  besi  instru- 
ment to  use  for  this  treatment.  After  the  anoscope  has  been  intro- 
duced and  the  obturator  removed,  a  slight  forward  and  backward 
movement  of  the  instrument,  under  the  guidance  of  the  eye,  allows 
the  hemorrhoid  to  fall  into  the  oblique  opening.  Asking  the  patient 
to  slightly  bear  down  assists  this  procedure. 

Quinin  and  urea  hydrochlorid  is  a  very  decided  hemostatic, 
and  a  hemorrhoid  that  has  been  bleeding  freely  for  some  time  will 
rarely  bleed  after  the  first  treatment.  The  drug  is  not  an  escharotic, 
but  a  most  excellent  local  anesthetic.  When  injected  into  the 
hemorrhoid  it  does  not  produce  an  inflammatory  reaction  or  spasm 
of  the  sphincters,  consequently  pain  is  very  seldom  complained  of. 
During  the  progress  of  these  treatments  the  patient  is  allowed  to 
continue  about  his  business  as  usual;  no  restrictions  whatever  are 
placed  upon  him. 

Electrolysis  in  the  treatment  of  internal  hemorrhoids  has  many 
advantages  over  cutting.  The  technic  can  be  successfully  carried 
out  in  the  office.  A  single  application  of  the  current  is  effectual 
in  ordinary  cases.  The  patient  needs  but  little  preparation  before 
treatment.  A  cathartic  the  night  before  and  an  enema  an  hour 
before  coming  to  the  office  should  be  sufficient  to  prevent  any 
interruption  or  delay  during  the  treatment.  After  the  usual 
antiseptic  cleansing,  the  patient  is  placed  in  the  left  lateral  position. 
A  short  proctoscope  is  introduced  and  the  hemorrhoid  brought  into 
view.  It  is  not  necessary  to  dilate  the  sphincters.  A  hypodermic 
syringe  is  used  to  introduce  a  local  anesthetic.  Eucain  may  be 
used,  but  the  percentage  must  be  very  low  because  the  solution 
does  not  ooze  away  as  in  cutting  operations.  A  larger  quantity 
of  fluid  is  necessary  for  pressure  anesthesia  than  when  injecting 
into  the  skin.  A  solution  of  0.1  per  cent,  is  sufficiently  concentrated 
to  secure  perfect  anesthesia.  Beta-eucain  lactate  has  the  advan- 
tage of  not  being  decomposed  by  boiling,  and  is  said  to  be  less 
toxic  than  cocain.  An  all-metal  syringe  of  two-dram  capacity, 
with  a  very  small  needle,  is  recommended.  The  hypodermic  injec- 
tion should  be  made  from  the  base  to  the  apex  of  the  hemorrhoid. 
^Yhen  the  tissue  is  distended  and  has  a  blanched  appearance,  the 
tumor  is  ready  for  treatment.  AYilliams1  recommends  a  ten-inch 
monopolar  platinum  electrode  (Fig.  154)  having  three  points 
arranged  in  a  row.  The  needles  should  be  passed  into  the  center 
of  the  tumor  after  it  is  no  longer  sensitive,  and  their  position 
changed  from  time  to  time  until  the  disintegration  of  the  tumor 
is  complete.     This  pole  is  attached  to  a  negative  electrode.     The 

1  Electricity  in  Rectal  Diseases,  New  York  Medical  Journal,  April  26,  1913. 


832  DISEASES  OF  THE  RECTUM 

current  should  never  be  interrupted.  The  rheostat  should  always 
be  turned  to  zero.  A  current  of  two  to  twenty  milliamperes  slowly 
turned  on  and  continued  five  to  ten  minutes  is  usually  sufficient 
to  treat  a  single  hemorrhoid.  As  soon  as  the  current  is  turned  on, 
bubbles  of  gas  form  in  the  shrinking  tumor,  giving  it  a  grayish- 
white  appearance.  The  chemical  effect  is  disintegration  of  the 
albuminous  constituents.  It  is  not  necessary  for  the  patient  to 
remain  in  bed.  When  there  are  several  hemorrhoids,  they  should 
be  treated  ten  days  to  two  weeks  apart.  There  is  no  hemorrhage 
during  or  after  the  treatment. 

The  surgical  operations  for  hemorrhoids  are:  ligature,  the  White- 
head operation  and  its  modifications,  and  the  clamp  and  cautery. 
The  reader  is  referred  to  works  on  surgery  for  detailed  descriptions 
of  these  operations.    • 


Fig.  154. — Hemorrhoidal  electrode.     (Williams.)     a,  needles;  b,  electrode;  c,  electric 
connection;  d,  electric  wires. 


MALIGNANT  GROWTHS. 

Carcinoma. — It  has  been  mentioned  in  the  paragraph  on  Tumors 
of  the  Intestine  that  the  great  majority,  70  to  80  per  cent.,  of  all 
the  cases  of  intestinal  carcinoma  are  carcinomata  of  the  rectum. 
The  development  of  a  rectal  carcinoma  is  very  insidious.  The  first 
symptoms  are  usually  connected  with  a  history  of  retardation  in 
the  evacuation  of  the  bowel,  the  course  of  which  resembles  that 
of  an  ordinary  chronic  constipation.  The  constipation  is  usually 
treated  by  purgatives.  Gradually,  however,  the  irregularity  in  the 
bowel  movements  assumes  more  striking  features.  The  patients 
are  obliged  to  go  frequently  to  stool,  but,  notwithstanding  great 
efforts,  only  small  quantities  of  fragmentary  fecal  masses  are 
expelled.  The  evacuation  at  this  stage  approximates  in  appearance 
the  so-called  fragmentary  stool  of  Boas  (see  page  672).  Defecation 
is  not  followed  by  the  usual  relief.     (Plate  XXVIII.) 

Symptoms. — One  symptom  which  Leaf  always  regards  with 
suspicion  is  the  constant  passage  of  flatus  through  the  anal  orifice. 
I  have  been  able  to  verify  the  value  of  this  symptom  in  the  detection 
of  the  growth. 

The  patients  complain  of  pressure  and  fulness  in  the  rectum  and 
a  backache  in  the  sacral  or  coccygeal  region.     Pains  of  various 


PLATE    XXVIII 


</ 


/ 


ft 


Carcinoma  of  the  Rectum  with  Dilatation  and    Ulceration 
of  the  Sigmoid  Flexure. 


MALIGNANT  GROWTHS  833 

degrees  gradually  appear.  The  appetite  diminishes  and  the 
patients  become  pale  and  emaciated.  The  stools  become  soft, 
then  liquid,  then  decomposed;  when  examined  carefully,  blood, 
mucus  and  pus  are  demonstrable.  By  digital  exploration  the 
carcinoma  is  discovered  situated  at  a  variable  distance  from  the 
anus.  It  presents  itself  either  as  a  spacious  cavity  \v\tji  rigid, 
ragged,  rough  walls  (especially  in  cases  of  deep-seated  carcinomata), 
or  as  an  isolated  annular  tumor  with  so  small  an  aperture  as  scarcely 
to  permit  the  insertion  of  a  finger  (especially  when  the  carcinoma  is 
located  high  up). 

The  cylindric  or  columnar  carcinoma  is  the  variety  that  most 
frequently  involves  the  rectum.  It  feels  like  a  raised,  warty 
growth,  embedded  in  the  rectal  walls  (Leaf). 

Diagnosis. — To  firmly  establish  the  diagnosis,  it  is  important 
to  ascertain  how  far  the  carcinoma  extends  upward;  this  is  accom- 
plished by  digital  examination  or  by  the  use  of  the  proctoscope. 
The  Roentgen  ray  is  of  great  assistance  (Plate  XXII,  Fig.  2). 
Other  important  features  are,  the  mobility  of  the  tumor,  and  the 
firmness  with  which  it  has  become  attached  to  the  periproctal 
tissues.     Metastases  are  most  frequently  found  in  the  liver. 

The  complications  of  rectal  carcinoma  are,  invasion  of  neighboring 
organs  (bladder,  genitals),  and  penetration  of  the  skin  of  the  anal 
region.  Perirectal  (peri-anal)  abscesses  are  rare.  The  differential 
diagnosis  between  carcinoma  and  syphilitic  stricture  of  the  rectum 
occasionally  offers  difficulties;  the  Wassermann  reaction  is  a  valuable 
aid.     The  serologic  tests  for  carcinoma  are  helpful  (see  page  543). 

Treatment. — Carcinomata  of  the  rectum  are  the  most  favorable 
of  all  the  intestinal  cancers  in  respect  to  treatment,  because  it  is 
possible  to  make  an  early  diagnosis  and  the  opportunity  is  thus 
afforded  to  radically  remove  them  by  surgical  intervention.  In 
every  case  of  carcinoma  of  the  rectum,  therefore,  the  first  considera- 
tion is  the  feasibility  of  operative  removal.  Generally  speaking, 
those  carcinomata  are  considered  operable  which  are  movable.  The 
degree  of  the  extension  and  involvement  of  the  carcinoma  is  not  of 
so  much  importance,  so  far  as  operation  is  concerned,  as  fixation. 
The  general  condition  of  the  patient  is  of  greatest  importance; 
operation  is  frequently  inopportune  because  of  marked  cachexia 
and  anemia. 

Many  permanent  recoveries  have  been  obtained  by  operation. 
Recurrences  and  metastases,  particularly  in  the  liver,  are  very  fre- 
quent; these  complications  soon  terminate  fatally,  even  after  a 
favorable  result  of  the  operation  per  se.  With  regard  to  the  func- 
tional effects  of  the  operation,  it  is  of  great  importance  to  preserve 
the  sphincter  if  possible;  but  even  so,  rectal  function  is  scarcely 
ever  as  perfect  as  before  the  operation.  When  it  is  impossible  to 
preserve  the  sphincter,  the  patients  are  unable  to  retain  either  feces 
or  flatus. 
53 


834  DISEASES  OF   THE  RECTUM 

Inoperable  carcinoma  of  the  rectum  is,  characteristically,  elon- 
gated, ulcerated,  ragged  in  outline,  and  firmly  embedded  in  and 
involving  the  surrounding  structures.  The  question  arises,  whether 
in  such  a  case  an  artificial  anus  should  be  established  before  severe 
symptoms  of  stricture  develop.  Many  surgeons  defer  the  operation 
of  colostomy  until  the  development  of  symptoms  of  ileus,  and  avoid 
the  artificial  anus  as  long  as  the  lumen  remains  tolerably  patent. 
There  can  be  no  doubt  that  for  many  sensitive  patients  an  artificial 
anus  is  absolutely  intolerable.  Suicide  under  such  conditions  is  not 
rare.  An  indifferent  patient,  on  the  contrary,  may  frequently 
be  able  to  accommodate  himself  fairly  well  to  the  artificial  anus. 
Here,  therefore,  the  question  of  the  individual  should  be  taken  into 
consideration.  A  colostomy  is  indicated  in  some  cases  for  the 
reason  that  by  diverting  the  course  of  the  feces  it  allows  perfect 
quiescence  of  the  carcinoma,  and  this  may  result  in  an  abatement 
of  the  inflammatory  processes,  with  cessation  of  hemorrhage  and 
ulcerative  discharge,  and  the  conversion  of  an  inoperable  carcinoma 
into  an  operable  one. 

Adenocarcinoma  responds  well  to  radium,  the  squamous-celled 
variety  not  so  readily. 

If  radical  or  palliative  operative  procedures  are  out  of  the  ques- 
tion, symptomatic  treatment  is  only  possible  by  means  of  internal 
medication.  The  strength  of  the  patient  should  be  maintained  as 
much  as  possible  by  proper  food,  rich  in  calories;  a  strictly  liquid 
diet  is  seldom  necessary.  Moreover,  the  stools  should  be  kept  as 
soft  and  semiliquid  as  possible  in  order  to  avoid  stagnation  from  hard 
fecal  masses  above  the  carcinoma.  This  is  best  accomplished  by  the 
administration  of  purgative  foods  (see  page  182)  and  mild  laxatives. 

Great  benefit  can  frequently  be  derived  from  liquid  petrolatum 
in  30-Gm.  (§j)  doses  three  times  a  day.  The  dose  can  usually  be 
taken  with  a  pinch  of  salt,  if  at  first  disliked.  The  oil  lubricates 
the  mucous  membrane  and  the  feces  and  renders  the  passage  of  the 
latter  less  irritating  to  the  ulcerated  neoplasm  (see  page  664). 

Pains  and  tenesmus  are  to  be  combated  by  opium,  morphin, 
codein,  and  belladonna,  by  mouth  or  subcutaneously,  and  occasion- 
ally" in  suppository  form.  Anodynes  should  be  used  freely  (page 
274). 

In  the  presence  of  markedly  fetid  discharges,  hemorrhages,  and 
purulent  disintegration,  attempts  may  be  made  to  counteract  these 
complications  by  irrigation  of  the  rectum  with  antiseptic  liquids 
or  by  means  of  the  dry  treatment  through  the  proctoscope  with 
the  powders  previously  named  (see  page  237).  The  results  thus 
obtained  are  occasionally  quite  satisfactory. 

Sarcoma. — Sarcomata  of  the  intestine  are  most  frequent  in  the 
small  intestine  and  the  rectum.  The  clinical  symptoms  of  sarcoma 
of  the  rectum  are,  in  general,  identical  with  those  of  carcinoma, 


BENIGN  GROWTHS  Kilo 

the  only  difference  being  the  more  rapid  course  of  the  sarcoma, 
due  to  its  quicker  growth.  Sarcoma  makes  its  appearance  earlier 
in  life  than  rectal  carcinoma.  The  surface  of  the  sarcomatous 
tumor  is  smooth  to  the  touch,  and  the  tumor  does  not  show  so 
marked  a  tendency  to  disintegration  as  does  carcinoma. 

Treatment. — The  treatment  is  similar  to  that  of  carcinoma  of 
the  rectum. 

BENIGN  GROWTHS. 

Polypi. — Polypi  of  the  intestine  are  classed  in  pathologic  anatomy 
as  adenomata,  and  are  situated  on  a  broad  base  or  connected  by 
a  narrow  pedicle  to  the  mucous  membrane.  They  may  occur 
singly,  but  are  usually  found  in  groups.  Their  size  varies  from 
that  of  a  pea  to  that  of  an  egg.  Though  no  part  of  the  intestine 
is  immune,  their  point  of  predilection  is  the  rectum.  A  single 
polyp\is,  or  even  a  small  group,  may  exist  without  producing 
any  symptoms.  Minute  hemorrhages  are  sometimes  due  to  this 
cause.  But  when  one  or  several  large  polypi  are  present  in  the 
rectum,  disagreeable  symptoms  follow,  and  profuse  bleeding  may 
occur;  pains  develop,  and  when  the  polypi  are  very  large  they 
narrow  the  intestinal  lumen  considerably  or  may  even  obstruct 
it  entirely.  Rectal  polypi  can  be  diagnosed  by  digital  exploration 
or  by  means  of  the  proctoscope.  They  can  be  distinguished  from 
malignant  neoplasms  by  their  complete  isolation,  by  the  pedicle, 
and  by  the  absence  of  ulceration  and  cachexia. 

Treatment. — Polypi  in  the  rectum  should  be  removed  radically, 
for  the  reason  that  they  are  apt,  under  certain  conditions,  to  undergo 
malignant  degeneration.  When  it  is  possible  to  bring  deep-seated 
polypi  out  of  the  anus,  they  should  be  ligated  and  cut  off.  Polypi 
situated  farther  up,  especially  those  with  pedicles,  may  be  removed 
through  the  proctoscope  with  a  long-handled  sharp  spoon  or  by 
means  of  a  snare  similar  to  that  employed  for  the  removal  of  small 
polypi  of  the  nose.  A  polypus  may  be  seized  with  a  sharp  hooked 
forceps  and  removed  by  torsion  or  by  careful  avulsion.  The  latter 
procedure  is  easy,  and  it  often  happens  that  pedunculated  polypi 
fall  off  spontaneously.  Polypi  may  likewise  be  extirpated  at  their 
base  by  means  of  the  electric  cautery  snare.  The  remaining  stump 
of  the  pedicle  of  the  polypus,  after  removal  of  the  latter,  is  slightly 
cauterized  with  nitrate  of  silver  in  order  to  prevent  hemorrhage. 
The  stumps  of  the  larger  sized  adenomata  and  polypi  may  be 
destroyed  by  means  of  intrarectal  Roentgen-ray  treatment.  Some 
cases  of  multiple  polyposis  are  benefited  by  radium. 

The  prognosis  assumes  a  much  more  serious  aspect  when,  instead 
of  a  few  polypi  or  a  single  isolated  one,  the  entire  rectum  is  closely 
studded  with  large  and  small  polypi — a  condition  which  is  designated 


836  DISEASES  OF  THE  RECTUM 

as  polyposis  recti.  These  cases  are  serious  for  the  reason  that  they 
are  very  prone  to  undergo  carcinomatous  degeneration  and  give 
rise  to  grave  chronic  hemorrhages;  every  dejection  is  accompanied 
by  the  spontaneous  discharge  of  blood,  serum,  pus,  and  mucus, 
frequently  in  such  volume  as  to  gradually  bring  about  great  emacia- 
tion and  anemia.  These  conditions  are  often  accompanied  by 
severe  pains  and  tenesmus.  The  effects  of  internal  and  surgical 
treatment  are  satisfactory.  Internally  hemostatic  medicaments 
(ergotin,  Hydrastis  canadensis,  hamamelis)  may  be  administered. 
The  local  treatment  consists  of  irrigations  with  astringent  and 
hemostatic  drugs,  such  as  tannic  acid,  alum,  and  gelatin.  A  few 
of  the  larger  nodules  should  be  removed,  and  this  operation  is 
occasionally  followed  by  improvement  of  the  entire  process.  The 
establishment  of  an  artificial  anus  sometimes  acts  beneficially. 

The  polyposis  recti  is  occasionally  accompanied  by  polyposis  of 
the  entire  large  intestine.  In  some  few  cases  a  family  predisposition 
to  polyposis  has  been  noted. 

Lipomata  and  Myomata. — Both  these  affections  are  very  rare. 
Lipomata  originate  in  the  submucous  coat,  and  their  favorite 
seat  is  the  rectum  or  the  large  intestine;  they  may  attain  con- 
siderable magnitude  (size  of  a  child's  head),  and  they  occur  either 
singly  or  in  groups.  Myomata  develop  from  the  mucous  or  sub- 
mucous coats  (internal  myoma),  or  from  the  subserous  coat  (ex- 
ternal myoma) ;  they  are  found  more  frequently  in  the  colon  than 
in  the  rectum;  no  age  is  exempt;  the  tumors  sometimes  attain 
to  the  size  of  a  man's  head. 

Internal  myomata  frequently  invest  the  mucous  membrane  in 
the  form  of  pedunculated  tumors  and  thus  give  the  impression  of 
ordinary  polypi;  under  such  circumstances  it  is  not  easy  to  make  a 
differential  diagnosis.  Clinically  they  are  marked  by  fecal  urgency, 
the  passage  of  blood  and  mucus,  and  by  the  signs  of  rectal 
stenosis. 

The  symptoms  of  external  myomata  are  less  characteristic. 
These  growths  may  possibly  form  adhesions  with  the  pelvic  organs, 
thus  causing  pressure  and  inducing  rectal  bleeding. 

Treatment. — The  treatment  of  lipomata  and  myomata  may  be 
expectant,  so  long  as  no  urgent  symptoms  are  manifest.  Spon- 
taneous expulsion  of  the  tumor  has,  though  rarely,  been  observed. 
Otherwise  only  the  radical  operation  is  indicated.  Internal  pedun- 
culated myomata  are  treated  similarly  to  polypi.  External  myo- 
mata are  to  be  operated  upon  like  carcinoma  of  the  rectum. 

Papillae. — Papillae  are  small  nipple-shaped  elevations,  frequently 
found  just  above  Hilton's  white  line.  They  are  of  elongated 
conical  shape,  and  may  undergo  mucoid  degeneration.  They  are 
the  cause  of  pruritus  and  many  neurotic  symptoms  and  are  highly 
sensitive  to  pressure. 


STRICTURES  OF   THE  RECTUM  s:!7 

Treatment.     Their   treatment   consists   in    radical    removal   from 
the  mucous  membrane  at  their  base. 


STRICTURES  OF  THE  RECTUM. 

Strictures  of  the  rectum  may  develop  in  consequence  of  diseases 
located  in  the  neighborhood  of  the  rectum,  or  from  a  diseased 
condition  of  the  rectum  itself.  Narrowing  from  the  outside  may 
be  induced  by  tmnors,  exudates,  stones  in  the  bladder,  or  hyper- 
trophy of  the  prostate.  Internal  strictures  may  be  caused  by 
fecal  lumps,  enteroliths,  tumors  of  the  rectum,  or  local  inflamma- 
tory affections  (Plate  XXII,  Fig.  3). 

All  diseases  of  the  rectum  which  heal  with  the  formation  of 
cicatrices  may  induce  narrowing  of  the  rectal  lumen.  This  is  the 
case  with  rectal  ulcers,  and  among  these,  in  direct  order  of  frequency, 
are  the  syphilitic  and  the  dysenteric  ulcers.  There  is  also  a  purely 
inflammatory  form  of  rectal  stenosis,  the  genesis  of  which  resembles 
that  of  chronic  inflammatory  hypertrophy  of  the  pylorus:  to  chronic 
proctitis  is  added  loss  of  mucous  membrane,  and  round-cell  infiltra- 
tion with  proliferation  of  the  interstitial  tissue.  Most  cases  of 
rectal  stenosis  are  in  women  who  have  or  have  had  syphilis.  The 
strictures  are,  as  a  rule,  situated  near  the  anus,  rarely  higher  up; 
there  is  a  more  or  less  extensive  stricture,  formed  by  tough  masses 
of  connective  tissue,  which  is  sometimes  associated  with  ulceration. 
Occasionally  the  entire  rectum  becomes  converted  into  a  rigid  tube. 
Xot  infrequently  several  strictures  are  present  simultaneously. 

Symptoms. — Patients  with  stricture  of  the  rectum  usually  neglect 
the  slight  initial  symptoms,  and  only  when  the  discomforts  become 
more  urgent  do  they  seek  medical  advice.  The  pathologic  nature 
of  the  stricture  determines  the  symptoms,  such  as  excretion  of 
blood,  pus,  mucus,  liquid  stools,  or  evacuation  of  firm  fecal  frag- 
ments of  small  size  alternating  with  diarrhea.  All  this  is  accom- 
panied by  pain  and  tenesmus  which  may  become  excruciating. 
Occasionally  the  sphincter  becomes  destroyed,  with  resulting 
incontinence  of  feces. 

Diagnosis. — The  stricture  is  diagnosed  by  digital  examination;  if 
high  up,  by  the  use  of  sounds  or  the  proctoscope.  Pus  and  blood 
in  the  feces  and  the  shape  of  the  stools  assist  in  the  diagnosis.  It 
is,  however,  often  extremely  difficult  to  recognize  strictures  located 
high  up. 

Rarely  there  occurs  a  congenital  stricture  of  the  rectum;  the 
diagnosis  is  readily  made  by  digital  examination. 

The  nature  of  the  stricture  often  remains  undetermined.  The 
distinction  between  syphilitic  and  dysenteric  strictures,  particularly, 
offers  great  difficulties.     The  most  important  distinction  to  be 


838 


DISEASES  OF   THE  RECTUM 


made  is  that  between  malignant  and  non-malignant.     In  a  general 
way  Tuttle1  distinguishes  them  as  follows  : 


Malignant  Stricture. 

Generally  occurs  in  persons  above 
thirty-five  years  of  age. 

Runs  its  course  ordinarily  in  two  or 
three  years.  Constitutional  symp- 
toms, such  as  loss  of  flesh  and 
strength,  appear  early  in  the  course 
of  the  disease. 

Hereditary  influence  probable. 

To  the  touch,  hard,  nodular,  without 
pedicle;  protrudes  into  the  rectum 
from  more  or  less  of  the  circumfer- 
ence of  the  gut,  but  not  equally;  it 
may  occur  as  a  deep  excavating 
ulcer  with  sharp  edges  and  in- 
durated base,  or  sometimes  as  a 
fungous,  granulating,  cauliflower 
growth.  May  be  movable,  but  is 
usually  attached  to  the  sacrum  and 
surrounding  parts. 

The  odor  is  nauseating,  gangrenous, 
and  unique. 


Non-malignant  Stricture. 

Occurs  at  any  age,  ordinarily  between 
twenty  and  fifty. 

The  patients  may  five  for  many  years 
with  it.  General  health  remains 
good  through  long  periods. 


No  hereditary  connections. 

To  the  touch  it  is  smooth,  hard,  and 
inelastic,  but  not  nodular.  A  dis- 
tinct cicatricial  or  fibrous  appear- 
ance upon  examination  through  the 
speculum. 

Rarely  attached  to  the  sacrum,  but 
sometimes  attached  to  organs  in 
the  anterior  portion  of  the  pelvis. 


The  odor  is  fecal  or  feculent,  accord- 
ing to  the  amount  of  ulceration. 

The  discharge  may  be  abundant  or 
limited,  thick  or  thin,  according  to 
the  nature  of  the  stricture. 


Treatment. — The  treatment  by  internal  medication  is  by  no  means 
successful  in  cases  of  rectal  stricture.  When  syphilis  is  suspected, 
antisyphilitic  treatment  should  be  instituted  at  once,  although  the 
results  are,  unfortunately,  often  negative.  Mild  aperients  are 
necessary,  in  order  to  alleviate,  to  a  degree  at  least,  the  very  harass- 
ing symptoms  of  stenosis  (see  page  283). 


Fig.  155. — Crede's  bougie. 

The  mechanical  non-surgical  treatment  of  strictures  is  of  great 
importance  and  consists  in  systematic  dilatation  and  stretching 
of  the  stenosed  part.  According  to  the  reports  of  various  authors, 
this  treatment  has  often  given  good  results.  It  must,  however, 
be  persevered  in  for  months,  and  requires  a  large  fund  of  patience 
on  the  part  of  both  physician  and  patient.  Bougies  of  various 
shapes  are  employed  for  dilatation.  As  the  sounding  must  be  done 
with  great  care  in  order  not  to  cause  any  injury  to  the  mucous 
membrane,  it  is  better  to  employ  solid  soft-rubber  rectal  sounds  or 


1  Diseases  of  the  Anus,  Rectum  and  Pelvic  Colon,  Second  Edition,  p.  492. 


STRICTURES  OF   THE  RECTUM 


s:i'.i 


soft-rubber  hollow  bougies  containing  a  metal  spiral  to  stiffen  them. 
Soft-rubber  Wales  bougies  (Fig.  105)  are  the  best  instruments  lor 
this  purpose.     With  great  caution,  hard-rubber  bougies  may  be 

used;  they  are  either  straight  or  curved,  as  Crede's  instrument 
(Fig.  155).  Care  must  always  he  exercised  lest  the  bougie  pass 
through  the  rectal  wall  instead  of  the  stenosed  canal. 

Dudley  Roberts  describes  an  apparatus  he  uses  for  gradual 
anal  dilatation  'Figs.  156  and  157).  To  an  inner  bag  of  rubber- 
ized cloth,  the  ends  made  bulbous  to  prevent  slipping  inward  or 
outward  when  distended,  is  attached  a  tube  of  like  material,  on 
the  end  of  which  is  fastened  a  small  stopcock;  a  hand  bulb,  valved 


Fig.  156.- 


-Rectal  dilator  deflated. 
(Roberts.) 


Fig.  157.- 


-Rectal  dilator  inflated. 
(Roberts.) 


to  prevent  the  backward  passage  of  air,  is  attached  to  the  stop- 
cock. Within  the  bag  and  extending  through  a  portion  of  the  tube 
is  a  slender  metal  rod  with  bulbous  ends;  this  is  a  simple  means  of 
giving  the  collapsed  bag  sufficient  rigidity  during  introduction. 
Outside  the  strong  dilating  bag  is  a  thin  elastic  cover  free  from 
seams,  which  gives  a  perfect  smoothness'  to  the  bag  at  all  stages  of 
dilatation.  The  method  of  use  is  exceedingly  simple,  and  few  direc- 
tions are  necessary.  The  bag  is  well  dusted  with  talcum  powder  or 
covered  with  an  emollient;  the  elastic  cover  is  then  slipped  on  and 
moved  around  to  completely  lubricate  apposed  surfaces.  Two- 
thirds  of  the  length  of  the  bag  is  introduced,  through  an  anal 
speculum,  and  slow  dilatation  is  started.  As  soon  as  discomfort  is 
felt  the  stopcock  is  turned  and  a  few  minutes  are  allowed  to  elapse 


840 


DISEASES  OF   THE  RECTUM 


in  order  that  the  voluntary  and  involuntary  spasm  may  be  relaxed. 
Gradually  the  dilatation  is  continued,  and  when  as  much  as  possible 
has  been  done  the  bag  is  left  in  place  for  ten  to  fifteen  minutes. 
The  patient  is  instructed  to  lie  flat  on  his  back  and  relax  completely. 
Successive  treatments  follow,  and  each  time  dilatation  is  found  to 
be  easier  until  a  normal  condition  is  established.     The  advantage 


Fig.  158. — Rectal  dilator,  closed.     (Rosenberg.) 

of  this  form  of  instrument  in  the  treatment  of  strictures  of  the 
rectum  above  the  anus  is  obvious. 

Other  useful  instruments  are  sea-tangle  tents,  and  bougies  with 
olive-pointed  ends  similar  to  the  esophageal  sound  with  an  olive 
point,  ^liitehead  has  described  an  apparatus  made  of  rubber 
which   is   introduced   deflated    into    the   stricture   and   afterward 


Fig.  159. — Rectal  dilator,  open.      (Rosenberg.) 


distended  with  water.  Dilatation  with  these  instruments  is  to 
take  place  daily  or  every  two  or  three  days,  at  first  for  a  few  minutes, 
and  later  gradually  prolonged  to  an  hour  or  more.  By  careful 
torsion  of  the  bougie  the  stretching  effect  may  be  enhanced.  In 
order  to  obtain  the  best  results  it  is  necessary  to  continue  the  treat- 
ment for  months,  with  a  constant  increase  in  the  caliber  of  the 
sounds,  and  to  repeat  the  process  from  time  to  time. 


PROCTITIS  841 

Rosenberg  recently  devised  an  instrument  for  stretching  strictures 

of  the  rectum  (Figs.  1 08  and  If)!)).  It  is  constructed  on  the  same 
principle  as  the  urethral  dilators;  apart  from  the  size,  it  differs 

in  construction  and  in  its  great  strength,  making  dilatation  possible 
even  when  the  strictures  are  very  firm  and  hard.  The  branches 
open  by  the  twisting  of  the  handle,  and  a  scale  permits  exact  reading 
of  the  degree  of  the  dilatation.  After  the  location  and  the  width 
of  the  stenosis  have  been  ascertained,  the  apparatus,  closed  and 
covered  with  a  condom,  is  introduced  into  the  stricture.  The 
branches  are  then  opened  carefully  a  millimeter  at  a  time,  by 
turning  the  lever,  until  resistance  is  encountered;  the  stretching 
is  then  continued  with  the  greatest  caution,  the  operator  constantly 
observing  the  scale  of  the  apparatus  and  the  face  of  the  patient. 
When  the  patient  experiences  great  tension  or  pain,  the  stretching 
is  discontinued  and  the  apparatus  is  left  in  situ  for  twenty  to  thirty 
minutes.  Should  it  then  be  possible  to  dilate  further,  this  is 
accomplished  most  carefully.  When  removing  the  apparatus  the 
branches  should  not  be  put  into  juxtaposition,  for  fear  of  catching 
and  compressing  a  fold  of  the  mucous  membrane.  It  is  said  that 
with  this  method  the  patient  experiences  only  a  feeling  of  tension, 
never  violent  pain;  the  irritation  of  the  cicatrix  and  mucous  mem- 
brane is  reduced  to  a  minimum,  and  the  degree  of  dilatation  is 
absolutely  within  the  hands  of  the  physician.  Therefore  improve- 
ment or  cure  results  much  more  rapidly  than  with  the  other  methods 
of  dilatation. 

When  these  bloodless  methods  do  not  accomplish  their  purpose 
it  becomes  necessary  to  resort  to  surgery. 

PROCTITIS. 

Primary  inflammation  of  the  mucous  membrane  of  the  rectum  is 
induced  principally  by  mechanical,  chemical  or  bacterial  irritants, 
which  find  their  way  into  the  rectum  either  with  the  feces  or  from 
the  outside.  Secondary  proctitis  is  found  associated  with  other 
diseases  of  the  rectum.  Primary  proctitis  occurs  in  both  acute  and 
chronic  forms,  and  may  remain  circumscribed  or  become  diffused 
over  the  entire  surface  of  the  rectum. 

Symptoms. — Acute  proctitis  is  accompanied  by  sensations  of 
pressure,  tension,  and  irritating  itching.  When  the  inflammation 
is  extensive  it  is  accompanied  by  pains  and  tenesmus,  which  some- 
times become  quite  severe.  Defecation  under  such  circumstances 
is  difficult.  Mucus,  blood  and  pus  are  excreted  with  the  feces. 
The  general  health  is  considerably  affected,  and  fever  may  be 
present. 

Diagnosis. — The  diagnosis  is  easily  established  by  the  aid  of  the 
proctoscope  (Fig.  37).  Chronic  proctitis  is  usually  a  secondary 
condition  and  is  found  associated  with  fissures,  strictures,  hemor- 


842  DISEASES  OF   THE  RECTUM 

rhoids,  and  foreign  bodies  in  the  rectum;  the  subjective  sensations 
are  usually  less  pronounced  than  those  of  acute  proctitis. 

Treatment. — Should  the  cause  of  acute  proctitis  be  found  (foreign 
bodies,  hard  scybala,  affections  of  neighboring  organs),  it  must 
of  course  receive  proper  attention.  Complete  bodily  rest  is  essen- 
tial. The  patient  should  be  placed  in  bed,  and  the  rectum  kept 
quiescent  by  the  administration  of  opium  by  mouth  or  by  sup- 
pository. Cool,  moist  applications  of  alum  or  fuller's  earth,  or  an 
ice-bag,  are  placed  over  the  perineum.  Leeches  may  be  applied 
in  the  vicinity  of  the  anus.  The  diet  should  consist  entirely  of 
liquids.  Lying  on  the  abdomen  or  on  one  side  often  lessens  the 
pains.  With  absolute  rest  the  inflammatory  symptoms  soon  recede. 
Activity  of  the  bowels  may  be  kept  up  by  the  administration  of 
castor  oil  or  by  enemata  of  olive  oil.  Direct  local  treatment  in 
acute  proctitis  is  not  indicated.  When  the  more  intense  inflam- 
matory irritation  has  passed  off,  the  mucous  membrane  may  be 
irrigated  with  chamomile  tea,  linseed  tea,  demulcents,  and  highly 
diluted  astringents;  if  necessary,  a  few  drops  of  tincture  of  opium 
may  be  added.  Acute  gonorrheal  proctitis  is  treated  locally  with 
antigonorrheal  remedies,  such  as  protargol  and  albargin  in  0.25 
to  1  per  cent,  solution  injected  into  the  rectum  and  retained  as 
long  as  thirty  minutes. 

In  chronic  proctitis  the  bowels  are  to  be  regulated,  and  the  rectum 
is  to  be  washed  out  once  or  twice  daily  with  the  usual  astringent 
and  antiseptic  solutions.  Irrigation  of  the  mucous  membrane  of 
the  rectum  with  hot  water  (110°  to  120°  F.)  is  valuable.  For  this 
purpose  the  irrigating  instrument  (Fig.  44)  should  be  used.  When 
the  instrument  has  been  introduced  into  the  rectum  it  should  remain 
there  until  the  seance  is  finished ;  if  removed,  before  all  the  hot  water 
has  come  away,  it  may  burn  the  skin.  It  must  be  remembered 
that  the  rectum  can  stand  water  at  a  higher  temperature  than  the 
skin.  Many  medicated  solutions  can  be  used  for  the  irrigation: 
phenol  0.5  to  1  per  cent.,  sodium  salicylate  1  per  cent.,  thymol  2 
per  cent.,  potassium  chlorate  1  per  cent.,  boric  acid  1  per  cent., 
hydrastis  1  per  cent.,  and  aqueous  fluid  extract  of  krameria  5  to 
20  per  cent.  When  a  decided  astringent  is  necessary,  nitrate  of 
silver  1  per  cent,  or  tannic  acid  3  per  cent,  in  distilled  water  can  be 
used.  Certain  oils,  as  cedar,  cajuput,  or  spruce,  may  also  be  used, 
being  mixed  with  the  water  or  solutions  by  the  addition  of  mag- 
nesium carbonate.  While  they  will  not  really  mix  with  the  water, 
these  oils  will  be  so  well  subdivided  that  they  will  find  their  way 
into  the  rectum  and  act  as  stimulants,  deodorants,  and  antiseptics 
(Albright). 

Hot  water  or  hot  medicated  solutions  are  essential  to  the  success- 
ful treatment  of  this  condition,  the  heat  being  probably  of  more 
value  than  the  medication.  Nothing  excels  hot  water  for  rectal 
pain,  either  by  irrigation  or  applied  externally  by  means  of  the 
sitz  bath  (see  page  250). 


ULCERS  OF  THE  RECTUM  843 

Astringent  and  antiseptic  remedies  may  also  be  applied  in  the 
form  of  suppositories,  or  introduced  into  the  rectum  directly  in 
the  form  of  semiliqUid  salves  by  means  of  an  ointment  syringe;  or 
the  salves  may  be  expressed  from  the  original  tin  tubes  connected 
with  a  piece  of  soft-rubber  tubing.  Rodari  obtained  good  results 
from  the  application  of  a  tannin-ichthyol  solution  followed  by  silver 
nitrate  suppositories.  In  the  morning,  if  possible  after  defecation, 
he  orders  the  injection  into  the  rectum  of  the  following  solution, 
which  is  to  be  retained  as  long  as  possible: 


1^ — Acidi  tannici 

Ichthyoli 

Alcoholis 

Aquae  destillatse       .      .      .       q.  s.  ad 
Misce. 
Sig. — To  be  injected. 

In  the  evening,  previous  to  retiring,  a  suppository  of  the  following 
composition  is  introduced: 

1$ — Argent i  nitratis 

Olei  theobromatis 

Misce  et  ft.  suppos.  no.  i. 


Gm. 

or 

Ce. 

0 

5 

gr.  vuss 

6 

0 

5iss 

10 

0 

5iiss 

100 

0 

oiij 

m.  or  Cc. 

0103 
3|0 

gr.  ss 
.    gr.  xlv 

Sitz  baths  and  local  astringents  assist  these  curative  measures. 
Sea  baths  are  also  said  to  act  beneficially.  The  drinking  cures  of 
Saratoga  and  Carlsbad  and  the  bitter  mineral  waters  are  valuable 
(see  page  252). 

The  cases  that  require  operation  are  those  in  which  there  is 
hypertrophy  of  the  mucous  membrane  and  enlargement  of  the 
rectal  valves  (hypertrophic  proctitis) .  In  such  cases  the  redundant 
tissue  is  pushed  down  in  front  of  the  descending  feces  and  forms  a 
temporary  obstruction  at  Houston's  valves.  Division  of  the  rectal 
valves  gives  more  room  for  the  feces,  and  this  operation  may  occa- 
sionallv  be  necessary  to  overcome  the  rectal  constipation  (Plate 
XX,  Figs.  3  and  4)/ 

ULCERS  OF  THE  RECTUM. 

All  varieties  of  ulcers  may  occur  in  the  rectum,  just  as  in  the 
large  and  small  intestine,  as  discussed  in  detail  in  the  chapters 
on  Intestinal  Ulcers.  They  are  tubercular,  dysenteric,  follicu- 
lar, and  stercoral,  and  the  ulcers  that  are  found  in  connection 
with  chronic  ulcerative  colitis.  Syphilitic  and  gonorrheal  ulcers 
are  frequently  observed  in  the  rectum,  although  they  are  rarely 
found  in  other  parts  of  the  intestinal  tract.  Syphilitic  ulcers 
in  the  rectum  develop  from  disintegrating  broad  condylomata 
or  from  necrotic  gummata.  They  are  usually  situated  low  down 
in  the  rectum,  and  sometimes  destroy  the  sphincter.  The  soft 
chancre  may  also  be  localized  about  the  anus.  Gonorrheal  ulcers 
subsequent  to  infection  of  the  mucous  membrane  with  gonococci 


844  DISEASES  OF   THE  RECTUM 

are  usually  located  on  the  anterior  and  posterior  walls  of  the  anal 
orifice.  Traumatic  ulcers  may  easily  result  from  the  careless 
application  of  enemata. 

Diagnosis. — The  diagnosis  of  ulcers  is  made  with  the  aid  of  digital 
and  proctoscopic  examinations,  the  study  of  the  feces  for  blood, 
pus,  tubercle  bacilli,  and  endamebse,  examination  of  the  genitals, 
previous  history,  and  study  of  the  clinical  condition,  particularly 
tuberculosis  of  the  lungs. 

Treatment. — In  cases  in  which  the  ulcers  are  due  to  syphilis  or 
tuberculosis,  the  cause  must  be  properly  treated.  Tuberc^.ar 
ulcers  offer  little  hope  in  this  respect,  since  tuberculosis  of  the  rectum 
is  practically  always  complicated  with  tubercular  infection  of  the 
large  or  small  intestine.  In  syphilitic  ulcers,  on  the  contrary, 
especially  if  they  are  of  rather  recent  origin,  specific  treatment  by 
arsphenamine,  mercury  and  the  iodids  often  effects  a  cure.  Re- 
covery is  much  more  difficult  and  uncertain  when  the  specific  ulcers 
are  of  long  standing,  with  large  ragged  surfaces  that  have  caused 
inflammatory  infiltrations  in  the  neighborhood.  In  such  cases, 
even  should  the  treatment  prove  successful,  the  hard  cicatricial 
tissue  present  is  apt  to  lead  to  stricture  of  the  rectum.  The  simple 
primary  sore  heals  in  the  same  manner  as  in  other  locations.  In 
gonorrheal  ulcerations,  if  the  patient  is  a  woman  the  genitals  should 
be  carefully  treated  in  order  to  prevent  reinfection  of  the  intestinal 
mucous  membrane. 

Besides  the  general  treatment,  local  treatment  of  the  ulcers  must 
be  considered.  The  dysenteric,  tubercular,  stercoral  and  follicular 
ulcers  are  treated  by  either  the  moist  or  the  dry  method,  as  described 
on  page  250.  In  syphilitic  and  gonorrheal  ulcers  the  diet  should 
be  carefully  regulated  in  such  a  manner  as  to  avoid  constipation. 
The  direct  treatment  consists  of  irrigation  of  the  rectal  mucous 
membrane  with  astringent  and  antiseptic  solutions,  as  silver  nitrate, 
sulphate  of  zinc,  tannin,  and  alum,  or  insufflation  of  antiseptic 
powders  through  the  proctoscope.  Cauterization  with  chlorid  of 
zinc  or  phenol  may  be  performed  through  the  proctoscope.  The 
above-named  medicaments  may  also  be  introduced  into  the  rectum 
in  the  form  of  thin  fluid  ointments  by  means  of  an  ointment  syringe. 
To  alleviate  the  pains,  anodynes,  such  as  anesthesm  and  orthoform, 
may  be  added  to  these  ointments. 

Gm.  or  Cc. 
ty— Orthoformi 5  0  5j 

Adipis  lanse  hydrosi, 

Petrolati aa     12  0  5"] 

Misce  et  ft.  unguentum. 

Sig. — To  be  introduced  with  an  ointment  syringe  twice  daily. 

Gm.  or  Cc. 

B; — Anesthesini, 

Bismuthi  subgallatis     .      .      .      .   aa       3|0  gr.  xlv 

Petrolati 30 10  §j 

Misce  et  ft.  unguentum. 

Sig. — Apply  with  a  syringe  twice  a  day. 


PROLAPSE  OF   THE  RECTUM  845 

When  the  pains  are  severe  the  following  astringent  ointmenl  <;ui 
be  used : 

Gra.  or  Co. 

1$ — Morphinse sulphatis Oil  gr.  ij 

I'nguenti  pluinbi, 

Petrolati aa     10  0  riii— 

Miser  tt  ft.  unguentum. 

Price  has  had  good  results  from  the  following: 

Gm.  or  Cc. 

1$ — Extract]  hamamelidis  destillatse   .      .     200 JO  §yij 

Extract!  hvdrastidis  (aqueous)      .      .       10  0  oiiss 

Phenolis 2  0  TTlxxx 

Glycerini 35  \0  3ix 

Misce. 

Sig. — Mix  one-half  teaspoonful  of  this  mixture  with  one-half  teaspoonful 
of  corn  starch  and  two  tablespoonfuls  of  warm  water.  Inject  into  the  rectum 
with  a  hard-rubber  syringe  and  retain  all  night. 

Irrigations  of  the  rectum  with  antiseptic  and  astringent  solutions, 
as  described  in  discussing  the  treatment  of  proctitis,  are  sometimes 
valuable. 

In  severe  cases  these  methods  of  treatment  occasionally  fail, 
because  recesses  and  stenoses  are  present  which  prevent  the  access 
of  the  medicaments  to  the  diseased  parts.  In  such  cases  surgical 
treatment  becomes  necessary.  Sometimes  a  thorough  curettement 
of  the  ulcers,  followed  by  the  actual  cautery,  and  divulsion  of  the 
sphincter,  will  effect  a  cure.  In  order  to  induce  drainage,  sphincter- 
otomy has  been  proposed.  In  ulcers  located  high  up,  colostomy 
and  local  treatment  through  the  artificial  opening  should  be  kept 
in  mind.  In  extensive  ulcerative  degeneration  it  sometimes  becomes 
necessary  to  resect  the  rectum. 

PROLAPSE  OF  THE  RECTUM. 

(Procidentia  Recti.) 

Prolapse  of  the  rectum  is  seen  most  frequently  in  infancy,  par- 
ticularly during  the  second  and  third  years  of  life ;  it  may  be  induced 
by  whooping-cough,  emaciation,  constipation,  intestinal  catarrh, 
rectal  catarrh,  or  tenesmus.  Prolapse  is  rather  rare  in  adults. 
The  same  causes  as  in  children  act  similarly;  and  besides,  hemor- 
rhoids, diseases  of  the  bladder  and  the  sexual  organs,  pregnancy, 
and  senile  atrophy  of  the  pelvic  muscles  may  induce  prolapse. 
The  development  of  this  displacement  proceeds  slowly:  at  first 
merely  the  anal  part  of  the  rectum  protrudes  during  defecation, 
and  later  a  large  portion  of  the  rectum.  ^When  the  prolapse  is 
extensive,  Douglas's  pouch  will  contain  intestinal  loops.  This 
condition  is  termed  hernia  recti. 

Prolapses  of  large  size  which  do  not  return  spontaneously  give 
rise  to  a  great  deal  of  discomfort.    The  mechanical  irritation  of  the 


846  DISEASES  OF   THE  RECTUM 

exposed  mucous  membrane  induces  inflammation,  catarrh,  and  the 
discharge  of  mucus.  Moreover,  hemorrhages,  erosions  and  ulcera- 
tions may  develop.  To  this  are  added  irritating  pains,  quite  apart 
from  the  constant  annoyance  caused  by  the  soiling  of  the  clothing 
and  the  fetid  odor  which  interferes  with  all  the  pleasure  of  life  and 
diminishes  all  social  interest.  When  the  prolapse  becomes  more 
chronic,  the  inflammatory  symptoms  generally  recede  and  the 
mucous  membrane  becomes  more  skin-like  and  less  sensitive. 
In  recent  cases  the  prolapse  may  become  incarcerated  and  gan- 
grenous. 

Treatment. — Internal  treatment  during  the  initial  stage  promises 
good  results.  Rather  small  and  recent  cases  of  prolapse  may  be 
cured  by  regulation  of  the  bowels,  avoidance  of  strong  bearing- 
down  pressure,  tonic  treatment  of  the  rectum  such  as  cold  washing 
and  sitz  baths,  with  astringent  solutions,  douches,  and,  in  children, 
painting  of  the  mucous  membrane  with  1-  to  5-per-cent.  solutions 
of  silver  nitrate. 

Treatment  in  cases  of  infantile  prolapse  demands,  according  to 
Mil  ward: 

(a)  Removal  of  the  exciting  cause. 

(b)  Measures  for  the  relief  of  the  predisposing  causes. 

(c)  Reduction  and  maintenance  in  position  of  the  displaced  gut. 

(a)  Vesical  calculus,  phimosis,  worms,  diarrhea,  constipation,  etc., 
must  be  efficiently  treated. 

(b)  Nutrition  must  be  improved  by  correcting  the  diet,  and 
debility  met  by  the  exhibition  of  tonics.  These  children  are  often 
underfed  or  ill-nourished  by  insufficiency  of  milk  and  the  substitu- 
tion of  artificial  foods.  In  the  way  of  tonics  they  may  be  given 
iron,  the  syrup  of  hypophosphites,  malt  extract,  and  cod-liver  oil. 

(c)  The  reduction  of  the  prolapse  is  effected  by  washing  it  with 
cold  water,  gently  squeezing  out  the  edema  with  the  flat  of  the 
four  fingers  and  the  thumb,  and  pressing  it  back  inside  the  anus 
between  the  expiratory  gasps.  The  fingers  should  be  well  oiled, 
and  the  child's  buttocks  slightly  raised.  When  the  prolapse  is 
quite  reduced,  a  small  pad  of  folded  lint  is  put  over  the  anus,  and 
the  buttocks  are  strapped  together  over  it.  Several  strips  of 
adhesive  plaster  are  necessary,  and  the  physician  should  finally  see 
that  the  reduction  is  maintained — that  the  rectal  mucous  membrane 
does  not  appear  at  the  edge  of  the  straps.  It  is  also  well  to  bandage 
the  thighs  together. 

In  adults  subcutaneous  injections  of  ergotin  0.1  to  0.2  Gm. 
(2  to  3  grains)  and  strychnin  0.001  to  0.002  (^  to  -^  grain)  may 
be  made  into  the  region.  These  injections  are  said  to  be  often 
efficacious  in  strengthening  the  muscular  power  of  the  sphincter. 
Similar  good  results  sometimes  follow  lavage  of  the  rectum  and 
intrarectal  faradization.  Massage  of  the  sphincter  is  said  to 
powerfully  strengthen  the  muscular  tonus.     After  reducing  the 


PROLAPSE  OF  THE  RECTUM  847 

displaced  gut,  circular  movements  arc  performed  with  the  index 
finger  outside  of  the  sphincter  ani,  kneading  of  the  muscles  of  the 
floor  of  the  pelvis,  and  finally  vibrations  with  the  finger  introduced 

into  the  rectum.  When  massage  is  practiced  in  this  manner  once 
or  twice  daily,  fairly  good  closure  of  the  sphincter  may  be  brought 
about. 

Non-replaceable  prolapse  should  be  prevented  from  protruding 
by  a  properly  adjusted  rectal  truss.  Such  an  apparatus  as  the 
rectal  truss  of  Esmarch  (Fig.  1(30)  is  of  value.  The  method  of 
application  is  sufficiently  shown  by  the  illustration.  This  appa- 
ratus is  made  as  a  firm  oval  bulb  of  rubber  about  the  length  of 
a  finger,  which  adapts  itself  to  the  size  and  situation  of  the  rectum. 
In  children,  one  of  the  best  methods  of  keeping  up  the  prolapsed 
rectum  is  to  strap  the  buttocks  together  after  each  defecation. 
It  is  occasionally  possible  to  retain  mild  prolapses  by  cotton  wads 
and  a  T-bandage. 


Fig.  160. — Rectal  truss.     (Esmarch.) 

A  recent  prolapse  may  usually  be  reduced  by  gentle  pressure 
of  the  finger  with  the  aid  of  an  oiled  compress.  When  a  prolapse 
has  existed  for  some  time  or  when  it  is  incarcerated,  it  may  become 
very  difficult  of  reduction.  The  patient  is  then  placed  in  the -left 
lateral  position,  with  the  pelvis  elevated,  and  attempts  are  made 
to  replace  the  prolapse  by  gentle  massage.  Should  this  be  unsuc- 
cessful, the  prolapse  may  be  gradually  reduced  by  a  cotton  wad 
and  a  T-bandage.  Sometimes  it  is  necessary  to  give  a  general 
anesthetic  or  to  induce  anesthesia  of  the  parts  by  the  intraspinal 
method  in  order  to  reduce  the  prolapse. 

Hajech  recommends  the  following  treatment  for  rectal  prolapse 
in  children:  A  tapering  piece  of  ice,  about  three  inches  long,  and 
one  inch  in  diameter  at  the  large  end,  is  wrapped  with  iodoform 
gauze,  and  its  point  pressed  gently  against  the  center  of  the  pro- 
lapsed mass  until  the  latter  is  replaced;  the  ice  tampon  will  remain 
in  the  rectum  without  the  help  of  any  retentive  bandage,  provided 
it  is  pushed  in  far  enough.  A  fresh  piece  of  ice  is  employed  in  this 
way  after  each  act  of  defecation.  This  treatment  soon  cures  the 
prolapse;  it  seems  to  act  by  emptying  the  bloodvessels  and  height- 
ening the  contractility  of  the  rectum. 

The  indication  for  surgical  intervention  depends  on  the  degree 
of  discomfort  experienced.    In  cases  in  which  there  are  permanently 


848 


DISEASES  OF   THE  RECTUM 


marked  disturbances,  pains  and  hemorrhages,  and  in  which  the 
above  internal  and  mechanical  procedures  do  not  lead  to  success, 
operative  measures  should  be  resorted  to.  Operations  for  prolapse 
are,  as  a  rule,  not  particularly  dangerous. 


PROCTOSPASM. 

The  tendency  of  the  intestine  to  contract  spasmodically  increases 
with  the  distance  the. contents  have  traveled:  the  severe  spasms 
occur  mostly  in  the  rectum  and  anus.  Proctospasm  leads  to 
irregular  evacuation  and  constipation,  particularly  when  a  spastic 

contraction  of  the  anal  muscles  ac- 
companies it.  The  spasm  is  usually 
followed  by  a  very  unpleasant,  even 
painful  pressure  of  desire  for  stool, 
without  result  (see  page  388). 

The  symptoms  of  proctospasm  are 
violent  pains  in  the  rectum,  with  a 
persistent  continuous  contraction  of 
the  anal  sphincter.  The  pains  occur 
usually  at  night  in  periodic  seizures; 
the  patient  awakens  with  the  pain, 
which  may  attain  great  intensity  and 
is  characterized  by  the  sensation  of 
spasmodic  anal  contraction.  This  is 
what  is  actually  taking  place.  If 
the  attempt  be  made  to  insert  the 
finger  into  the  anus,  this  will  be  found 
to  be  scarcely  possible.  The  attack 
usually  persists  for  some  minutes. 

The  tendency  toward  constriction 
of  the  lower  sections  of  the  intestine, 
easily  recognizable  roentgenographi- 
cally,  usually  develops  secondarily 
from  local  affections  of  the  rectum  and 
the  anus — inflammations,  ulcers,  fis- 
sures, hemorrhoids,  and  foreign  bodies 
— or  from  inflammation  of  the  pelvic  organs  in  the  female  or  cystitis 
and  affections  of  the  prostate  in  the  male.  Proctospasm  arises  also 
through  irritation  of  the  vegetative  nervous  system  of  the  pelvic 
area,  e.  g.,  in  crises  of  tabes,  hysteria,  and  neurasthenia.  Tenesmus 
with  intense  pains,  which  increase  paroxysmally  up  to  attacks  of 
weakness,  occurs  during  the  passage  of  the  stool,  and  continues  for 
some  time  after;  it  may  even  extend  to  the  bladder  and  induce 
ischuria.  The  diagnosis  is  made  by  digital  examination  by  way  of 
the  rectum,  or  by  roentgenologic  examination  after  an  enema  of 
bismuth  emulsion. 


Fig.  161. — Rectal  refrigerator. 
(Atzperger.) 


PARESIS  AND  PARALYSIS  OF  THE  RECTUM  849 

Treatment.-  In  cases  of  purely  functional  proctospasm  the 
treatment  must  be  directed  to  the  general  nervous  disease  under- 
lying the  spasm.  The  local  measures  especially  to  be  considered 
are:  galvanization  of  the  abdomen  and  rectum  with  weak  currents, 
dilatation  of  the  anus  with  rectal  sounds  of  increasing  sizes,  and 
application  of  the  rectal  refrigerator.  Asperger's  apparatus 
(Fig,  161)  is  a  useful  instrument  for  this  purpose.  This  rectal 
refrigerator  consists  of  a  hollow  metal  cone  (a)  about  seven  centi- 
meters (2$  inches)  long,  furnished  with  a  contrivance  for  the  circu- 
lation of  cold  water.  The  end  of  the  instrument  is  thoroughly 
lubricated  and  inserted  into  the  rectum,  and  water  of  the  desired 
temperature  is  allowed  to  circulate.  Occasionally  hot  water 
(100°  F.)  acts  beneficially.  Internally  the  bromids  should  be 
given  or  attempts  should  be  made  to  prevent  the  development  of 
the  attacks  by  the  administration  of  opium,  morphin,  belladonna, 
codein,  or  cocain,  by  mouth  or  as  suppositories  (see  page  658). 
Should  there  be  spastic  constipation  (see  Chapter  XXXVII),  it 
must  be  carefully  treated.  Papaverin  or  benzyl  benzoate  will 
relieve  the  spasm  (see  page  276). 

PARESIS  AND  PARALYSIS  OF  THE  RECTUM. 

Paresis  and  paralysis  of  the  rectum  are  very  rare  as  primary  ner- 
vous conditions.  They  are  most  frequent  as  a  result  of  local  rectal 
affections  (prolapse,  tumors,  proctitis,  hemorrhoids),  diseases  of 
the  genitals  (hypertrophy  of  the  prostate,  strictures  of  the  urethra) , 
chronic  constipation,  and  organic  diseases  of  the  brain  and  spinal 
cord.  The  diagnosis  is  made  by  inserting  the  finger  and  ascertaining 
the  absolute  relaxation  and  inability  of  the  sphincter  ani  to  close. 
Patients  are  unable  to  retain  the  feces  during  bodily  exertion, 
coughing  or  sneezing.  In  mild  cases  involuntary  defecation  takes 
place  only  with  diarrhea,  but  in  severe  cases  formed  fecal  matter 
is  discharged  involuntarily. 

Treatment. — The  causative  disease,  whatever  it  may  be,  must 
be  properly  treated.  If  none  is  discoverable,  the  treatment  should 
be  directed  toward  improvement  of  the  function  of  the  sphincter. 
This  is  primarily  attained  by  faradization  of  the  rectum,  continued 
regularly  for  a  long  time.  The  diet  must  be  arranged  as  indicated 
by  the  condition  of  the  stools.  Diarrhea  must  be  treated  with 
antidiarrheic  remedies.  Should  the  feces  be  very  firm,  they  should 
be  rendered  softer  by  means  of  the  diet,  because  then  the  evacuation 
of  the  bowel  is  more  complete  and  the  involuntary  escape  of  feces 
is  restricted.  The  patient  should  carefully  regulate  the  time  of 
taking  food  and,  as  far  as  possible,  of  evacuation  of  the  bowels. 
Should  masses  of  feces  be  firmly  lodged  in  the  ampulla  recti  and 
remain  stationary  there,  they  must  be  softened  by  irrigation.  The 
sphincter  ani  may  be  rendered  more  contractile  by  cold  sitz  baths, 
54 


850  DISEASES  OF  THE  RECTUM 

cold  ablutions  of  the  perineum,  and  cold  douches  of  the  rectum. 
Strychnin  may  be  given  subcutaneously,  0.001  to  0.002  Gm.  (^  to 
■%=$  grain),  or  in  suppositories  as  extract  of  nux  vomica  0.03  Gm. 

(|  grain),  twice  daily  (see  Chapter  XI). 

COCCYGODYNIA. 

Coccygodynia,  or  pain  in  the  region  of  the  coccyx,  occurs  in 
women,  and  is  increased  by  walking,  micturition,  and  defecation. 
Another  affection  which  may  simulate  rectal  neuralgia  is  the  anal 
crisis  of  tabes. 

Treatment. — Ely  has  suggested  a  treatment  for  coccygodynia 
which  I  have  found  highly  satisfactory.  It  consists  of  massage 
of  the  coccyx  by  means  of  the  forefinger  in  the  rectum  and  the 
thumb  on  the  outside,  holding  the  bone  between  them.  The  bone 
is  moved  backward  and  forward,  and  the  soft  parts  are  moved  about 
on  the  bone.  The  manipulation  is  begun  very  lightly,  and  gradually 
increased  in  force  as  the  patient  becomes  less  sensitive.  Usually 
a  few  treatments  at  intervals  of  two  or  three  days  will  suffice  for  a 
cure.     The  improvement  is  almost  immediate. 

It  is  observed  that  a  sedative  ointment  rubbed  into  the  skin  of 
the  coccygeal  region  sometimes  gives  relief.  The  following  oint- 
ment is  often  found  to  be  efficacious: 

Gm.  or  Cc. 
]$ — Tincturse  aconiti      ......       2|0  5ss 

Unguenti  belladonnas    .      .  ■    .      .  30  (0  5  i 

Misce  et  ft.  unguentum. 
Sig. — Apply  thoroughly. 

Alcohol  induces  degeneration  of  sensory  nerves  and  is  useful  in 
cases  of  coccygodynia.  Ten  to  twenty  minims  of  80-per-cent. 
alcohol  are  slowly  injected  at  the  point  of  pain.  With  the  right 
index  finger  in  the  rectum,  the  maximum  tenderness  is  determined  by 
counter-pressure  with  the  thumb  on  the  outside.  The  finger  in  the 
rectum  acts  as  a  guide  to  the  needle,  directing  it  to  the  painful 
spot,  at  the  same  time  guarding  against  perforation.  The  pain 
from  the  puncture  lasts  a  few  minutes  and  is  followed  by  a  dull  ache. 
Four  or  five  injections  at  intervals  of  one  week  are  necessary. 

The  application  of  the  actual  cautery  is  said  to  constitute  the 
most  certain  remedy.  A  Paquelin  cautery  is  used  to  cauterize 
the  skin  over  the  sacral  foramina  on  each  side,  the  skin  being  burnt 
deeply,  and  the  resulting  eschar  is  then  treated  as  an  ordinary 
granulating  wound.     Coccygectomy  may  be  necessary. 


CHAPTER  LIV. 

DISEASES  OF  THE  ANUS. 

Pruritus  Ani;  Anal  Fistula;  Fissure  of  the  Anus. 

PRURITUS  ANI. 

Painful  itching  in  the  anal  region  is  called  pruritus  ani.  This 
itching  is  merely  a  symptom  and  not  a  rectal  disease  per  se.  There 
are  many  causes  of  this  distressing  affection:  constipation,  hemor- 
rhoids, fissure,  fistula,  ulcer,  proctitis,  polypi,  papilla?,  inverted 
hairs,  jaundice,  gout,  carcinoma,  syphilis,  foreign  bodies,  diabetes, 
uterine  diseases.  Pediculi  and  ascarides  are  frequently  associated 
with  pruritus  ani.  Wallis  believes  the  pruritus  is  due  to  a  small 
ulcer  located  between  the  two  sphincters.  He  says  that  in  over 
90  per  cent,  of  the  cases  so  examined  a  shallow  ulcer  was  found, 
usually  between  the  two  sphincters,  more  often  in  the  posterior 
half  than  in  the  anterior,  and  generally  in  the  dorsal  midline;  in 
some  cases  there  is  more  than  one  ulcer,  and  again  in  others  there 
are  various  clefts  which  occasionally  almost  surround  the  bowel. 
The  ulcer  is  not  easy  to  recognize  by  the  touch,  and  it  requires  a 
certain  amount  of  practice  to  appreciate  its  presence.  In  the 
first  place  it  must  be  remembered  that  it  is  only  just  within  the 
anal  margin  and  always  below  the  internal  sphincter.  The  smooth 
feeling  of  the  healthy  lining  membrane  will  be  recognized,  but  when 
the  finger  comes  to  this  abraded  or  ulcerated  surface  the  smooth 
feeling  disappears  and  a  slightly  raised  margin  can  be  felt  around 
the  rough  surface.  There  is  sometimes  pain,  but  more  often  none, 
associated  with  the  examination.  When  the  speculum  is  introduced 
it  must  be  remembered  that  the  tissues  are  pushed  in,  some  little 
distance,  by  the  instrument,  and  so  the  ulcer  will  appear  to  be 
higher  up  than  it  really  is.  If  after  its  introduction  the  speculum 
be  opened  to  its  fullest  extent,  the  inexperienced  observer  will 
probably  not  recognize  the  ulcer;  but  if  it  be  only  slightly  opened 
and  a  careful  view  with  a  headlight  obtained,  the  ulcer  can  be 
clearly  seen  as  a  shallow,  oval,  livid  abrasion,  differing  markedly, 
and  mainly  in  color,  from  the  normal  mucous  membrane.  Here, 
then,  is  a  definite  lesion  in  a  so  far  indefinite  disease,  and  it  has 
seemed  reasonable  to  believe  that  it  might  be  the  cause  of  the 
irritation. 

According  to  Beach,  the  distinct  pathogenesis  of  pruritus  ani 
consists  of  single  or  multiple  burrowings  from  the  anal  pockets, 


852 


DISEASES  OF   THE  ANUS 


emitting  a  serous  or  seropumlent  substance;  the  sinus  may  be 
complete  or  blind  and  is  always  accompanied  by  proctitis,  and  fre- 
quently by  cryptitis  and  small  ulcers  at  the  anorectal  line.  There 
is  occasionally  a  causal  relationship  between  tabes  and  pruritus. 
This  possibility  should  be  kept  in  mind. 

Many  cases  of  pruritus  ani  are  due  to  infection  by  the  Strepto- 
coccus fecalis,  the  portal  of  entry  being  the  anal  canal. 

Pruritus  ani  essentialis  is  due  not  to  a  local  but  to  a  constitutional 
cause.  It  is  a  primary  affection,  conditioned  upon  trophic  changes 
in  the  nerves  supplying  the  parts.  In  examining  a  well  developed 
and  well  established  case  of  this  kind  it  is  noticed  that  the  skin  of 
the  anus  and  immediate  vicinity  has  become  thickened,  is  drier  than 
normal,  and  has  lost  its  pliability;  that  it  is  raised  into  numer- 
ous radiating  folds  from  which  the  normal  coloring  matter  of  the 
skin  is  absent;  it  presents  a  grayish,  parchment-like  appearance. 
All  these  changes  in  the  condition  of  the  skin  can  be  readily 
accounted  for  if  we  assume  that  the  primary  cause  of  the  trouble  is  a 
faulty  nerve  supply  of  the  parts.  The  loss  of  pigment  is  due  to 
absorption  of  the  coloring  matter  of  the  deeper  layer  of  the  skin, 
induced  not  by  irritation  of  the  parts  from  scratching,  but  by 
abnormal  innervation.  The  appearance  of  the  skin  is  quite  typical 
and  should  be  recognized  as  pathognomonic.  The  chronic  inflam- 
mation of  the  epidermis  completely  alters  its  character;  it  becomes 
largely  infiltrated  with  fibrous  tissue,  loses  its  elasticity,  and  becomes 
covered  with  dead  and  sodden  epithelium  (YVallis). 

The  skin  in  pruritus  ani  may  be  either  moist  or  dry.  The  dry, 
scaly  type  is  usually  found  in  neurotic  subjects,  while  the  moist 
variety  is  found  in  the  plethoric.  The  anal  zone  is  eczematous 
for  the  space  of  perhaps  an  inch  on  every  side,  or  it  may  be  well 
over  the  buttocks,  the  eczema  being  the  result  of  scratching  or  of 
serous  discharges  from  the  anal  canal. 

The  following,  according  to  Leaf,  are  the  local  and  general 
conditions  usually  found  associated  with  pruritus: 


Local. 

1.  Disease  of  the  colon,  rectum,  or 

anus,  especially  fissure,  ulcer, 
chronic  ulceration,  polypi,  piles, 
prolapse  of  mucous  membrane, 
fistula,  condylomata,  malignant 
growths. 

2.  Skin  affections  of  the   anogluteal 

region,  erythema,  eczema,  tinea 
circinata  caused  by  the  tricho- 
phyton. 

3.  Thread  worms. 

4.  Diseases  of  neighboring  organs — 

uterus,  ovaries,  bladder,  pros- 
tate, etc. 

5.  Uncleanliness. 


General. 

1.  Irregularities  in  diet.  Consump- 
tion of  shellfish,  lobster,  or 
salmon.  Drinking  tea,  coffee, 
cocoa,  or  beer. 


2.  Constipation.     Negligence  in  at- 
tending to  nature's  calls. 


3.  Gout,   diabetes,    Bright's   disease, 

rheumatism,  syphilis. 

4.  Overwork. 


5.  Irritable  or  neurotic  temperament. 


PRURITUS  AN1  853 

The  Itching  may  become  intolerable,  especially  in  the  warmth 
of  the  bed.  No1  only  children,  hut  adults  also,  arc  apt  to  scratch 
the  itching  parts  until  open  sores  result. 

Treatment.-  The  radical  treatment  consists  in  removal  of  the 
cause.  Constipation  must  always  receive  proper  treatment  (see 
Chapter  XXXVII  on  Chronic  Constipation).  The  stagnation  of 
['vcv*  produces  venous  congestion,  which  superinduces  excretion  of 
mucus,  thus  keeping  the  anus  moist  and  provoking  dermatitis.  The 
same  thing  occurs  in  hemorrhoids,  fissure,  fistula,  ulcers,  proctitis, 
prolapse,  and  neoplasms.  It  is  of  the  utmost  importance  that  the 
anal  region  be  kept  clean.  Fecal  soiling  together  with  slight  mois- 
ture may  cause  intolerable  pruritus.  The  use  of  printed  paper  and 
coarse  toilet  paper  for  the  toilet  must  be  prohibited.  Pediculi  and 
worms  must  receive  due  attention.  This  is  important  in  the  pru- 
ritus ani  of  children,  for  intestinal  worms  are  often  present  (see  page 
804). 

Any  general  disease  implicated  must  have  proper  consideration; 
this  includes  the  treatment  of  diabetes,  gout,  rheumatism,  chole- 
cystitis with  obstructive  jaundice,  and  uremia.  Highly  seasoned 
food,  lobster,  crab,  and  strong  tea  or  coffee  must  be  interdicted,  as 
well  as  all  alcoholic  drinks  and  tobacco.  An  enlarged  prostate  or 
a  displaced  uterus  must  be  corrected.  Vaginal  discharges  require 
local  treatment.  Primary  skin  diseases,  such  as  eczema,  herpes, 
and  ringworm,  must  receive  proper  attention. 

While  treating  the  underlying  cause,  some  direct  relief  of  the 
itching  must  be  effected  if  possible.  Goodell  recommends  the 
following  soothing  application: 

Gm.  or  Cc. 
1^ — Chloralis  hydratis, 

Camphorse    .      .      .•     .      .      .      .   aa     15|0  5ss 

M.  et  adde, 
Acidi  borici, 

Unguenti  simplicis aa     15 10  §ss 

Misce. 
Sig. — Apply  with  a  brush  three  times  daily,  after  cleansing  the  parts  with 
hot  water. 

It  is  sometimes  advisable  to  add  to  the  above  ointment  I  to 
lh  grams  (15  to  20  grains)  of  phenol,  and  in  other  instances  1 
to  lh  grams  of  menthol.  Applied  at  bedtime  this  will  often  insure 
a  good  night's  rest. 

Compound  tincture  of  benzoin  is  a  mild  styptic  and  antiseptic. 
It  can  be  applied  to  the  anal  region  every  night.  The  balsam  causes 
all  the  small  cracks  to  heal.  The  application  must  be  continued 
for  several  weeks.  If  the  parts  are  moist  they  may  be  dusted  with 
starch,  calomel,  bismuth  subnitrate,  zinc  oxid,  boric  acid,  prepared 
chalk,  sulphur,  or  Bulkley's  antipruritic  powder — which  is  prepared 
by  rubbing  together  4  Gm.  (3j)  each  of  camphor  and  chloral  until 
liquefied,  and  adding  this  to  30  Gm.  (§j)  of  starch. 


§54  DISEASES  OF   THE  ANUS 

Long  persisting  anal  pruritus  can  frequently  be  relieved  by 
rubbing  the  region  with  dry  calomel.  The  part  is  first  wiped  dry 
with  absorbent  cotton,  and,  with  a  moistened  finger  cot  over  the 
index  finger,  the  powder  is  rubbed  thoroughly  into  the  crevices. 
After  four  or  five  applications  the  itching  usually  subsides  per- 
manently. 

Daily  ablution  of  the  anus  with  hot  water  and  soap  followed  by 
friction  of  the  anal  region  with  a  70-per-cent.  alcohol  and  1 :  1000 
sublimate  solution  will  often  afford  relief.  The  following  mixture 
is  very  efficacious: 

Gm.  or  Cc. 

1^ — Glycerini, 

Alcoholis aa     60 10  §ij 

Acidi  salicylici 2[0  3ss 

Misce. 
Sig. — To  be  applied  several  times  daily  after  a  hot  ablution  of  the  anal 
region. 

Should  the  itching  interfere  with  sleep,  the  local  application  of 
hot  water  for  fifteen  to  twenty  minutes  at  bedtime  will  usually 
procure  a  night's  rest  for  the  patient. 


Fig.  162. — Anal  ointment  introducer. 


Citrine  ointment  (U.  S.  P.)  is  frequently  useful.  It  can  be 
applied  through  the  ointment  introducer  or  pile  pipe  (Fig.  162). 
As  a  soothing,  non-irritant  application  the  resorcinol  ointment  of 
the  National  Formulary  can  be  used  with  the  pile  pipe. 


ruiurn  s    \\i 


655 


Tht'  following  is  soothing  and  is  said  (o  give  almost  immediate 
relief: 

<  im,  or  c  !o. 


\\    -Phenolis 

1  [ydrargyri  chloridi  initis, 

Pick 

Mentholis  .... 
Zinci  oxidi  .... 
Petrolati       .... 


gr.  xx 

5i 

gr.  ij 
3i 
3yj 
5ij 


Adipis  lanae  hydrosi 8 

Misce  et  ft.  unguentum. 
Sig. — Bathe  with  water  as  hot  us  can  be  borne  and  apply  the  ointment  twice 
daily. 


The  following  has  also  been  found  very  beneficial: 


U 


Gm. 

or  Cc. 

4 

0 

5.1 

2 

0 

3ss 

15 

0 

5ss 

15 

0 

5ss 

Anesthesini  .... 

Zinci  oxidi     .... 

Adipis  lanse  hydrosi 

Petrolati        .... 
Misce  et  ft.  unguentum. 
Sig. — Apply  three  times  daily. 


Pruritus  being  a  result  of  pressure  upon  the  nerve  terminals  by 
increased  blood  supply  on  the  one  hand  and  a  scaly  or  horny  con- 
dition of  the  skin  on  the  other,  the  chief  indication  is  to  diminish 
the  blood  supply  and  desensitize  the  nerve  endings,  and  this  indi- 
cation is  fully  met  by  the  hypodermic  injection  of  quinin  and 
urea  hydrochlorid  solution.  The  needle  is  inserted  about  an  inch 
from  the  anal  margin,  on  a  line  with  the  tuberosity  of  the  ischium, 
and  a  0.5  per-cent.  solution  of  the  double  salt  directed  first  toward 
the  back  of  the  anus,  then  laterally,  and  again,  with  a  guiding 
finger  in  the  anus,  well  toward  the  perineal  raphe.  Thus  three  injec- 
tions are  made  from  one  point  of  insertion  (about  30  minims  being 
introduced  at  each  injection),  and  this  operation  is  repeated  on  the 
other  side  of  the  anus.  The  liquid  is  placed  as  near  as  possible  to 
the  anal  mucosa,  but  the  sphincter  must  be  avoided.  The  relief 
afforded  by  this  procedure  lasts  from  two  to  four  weeks. 

Gratifying  results  are  often  obtained  from  the  use  of  anal  dilators. 
The  patient,  immediately  after  retiring,  inserts  into  the  anus  as 
large  a  dilator  as  it  will  comfortably  accommodate,  and  allows  it  to 
remain  at  least  fifteen  minutes.  Let  him  do  this  every  night  until 
the  muscles  have  relaxed  sufficiently  to  receive  a  larger  size.  This 
treatment  should  be  continued,  as  in  other  instances  of  gradual 
dilatation,  until  the  sphincter  is  more  relaxed  than  it  is  intended 
ultimately  to  be.  This  method,  unlike  divulsion,  does  not  injure 
the  mucous  membrane.  The  small,  blunt,  hard -rubber  instruments 
found  in  the  shops  in  graduated  sizes  are  all  that  is  necessary;  and 
they  are  inexpensive  (Fig.  52).  The  treatment  is  to  be  followed 
by  extreme  dilatation  with  the  Roberts  rectal  dilator  (Figs.  156 
and  157). 


856  DISEASES  OF  THE  ANUS 

Allingham  has  used  an  anal  plug  (Figs.  163  and  164)  to  prevent 
nocturnal  itching.  The  plug  exercises  pressure  upon  the  venous 
plexuses  and  filaments  of  nerves  close  to  the  anus.  It  was  suggested 
to  him  by  patients  telling  him  they  could  obtain  relief  and  sleep  by 
introducing  the  end  of  the  forefinger  into  the  anus  and  making 
pressure  that  instantly  arrested  the  irritation. 

In  exceptionally  violent  cases  where  local  applications  give  no 
relief  the  Roentgen  ray  may  have  the  desired  effect.  Two  or  three 
applications  at  three-week  intervals  have  been  found  to  be  effec- 
tual. Relief  usually  comes  fifteen  days  after  the  first  application. 
The  cases  which  are  the  most  benefited  by  the  Roentgen  ray  are 
those  in  which  lichenification  has  set  in,  with  or  without  an 
eczematous  condition  and  oozing. 


Fig.  163.— Anal  plug.  Fig.  164.— Anal  plug. 

Pruritus  ani  is  an  affection  which  one  would  not  think  of  referring 
to  bacterial  infection.  Wright  says  that  it  had  not  occurred  to 
him  that  it  might  be  due  to  such  a  cause  until  a  patient  who  was 
suffering  from  this  condition  was  referred  to  him  for  the  treatment 
of  an  associated  furunculosis.  He  now  finds  it  difficult  to  under- 
stand how  it  is  possible  to  look  at  pruritus  ani  from  any  other  point 
of  view  than  that  of  a  bacterial  infection.  He  has  found  in  a  number 
of  cases  that  a  platinum  loop  applied  to  the  seat  of  irritation  brought 
away  quite  astonishing  numbers  of  bacteria,  invariably  staphylo- 
cocci and  pseudodiphtheria  bacilli,  and  occasionally  tetrads;  and 
in  each  of  these  cases  life  has  been  rendered  comfortable  or,  if  not 
quite  comfortable,  at  any  rate  quite  endurable,  by  the  use  of  appro- 
priate bacterial  vaccines.  Murray  had  cultures  made  in  98  cases 
of  pruritus  ani,  and  found  Streptococcus  fecalis  present  externally 
on  the  skin  in  85  of  the  cases.  A  blood  test  in  each  of  the  85  cases 
further  showed  that  the  patient's  resistance  against  streptococci  was 
low,  while  it  remained  high  for  other  microorganisms.  All  of  these 
cases  were  treated  with  autogenous  vaccine,  with  the  result  that 
itching  ceased  and  streptococci  ceased  to  be  found  in  smear  and 
swab  after  a  period  of  treatment  varying  from  the  first  to  the  eighth 
injection.  In  one  case  a  lowered  resistance  to  the  Bacillus  coli  was 
also  found,  and  in  this  case  vaccines  of  both  organisms  were  used. 


AXAL  PISTUL  I  s:,r 

Should  these  methods  fail,  it  is  frequently  Imperative  to  resort 
to  surgical  measures.  It  may  be  necessary  to  remove  hypertro- 
phic! skin  folds.  Anal  poekets  must  be  opened  and  drained.  Anal 
papiihe  are  to  be  removed.  The  operation  devised  by  Ball  has 
given  the  best  results;  it  consists  in  dividing  all  the  sensory  nerves 
supplying  the  skin  of  the  anus  and  anal  canal  which  proceed  from 
branches  of  the  third  and  fourth  sacral  nerves.  This  operation 
renders  the  region  superficially  anesthetic,  and  the  pruritus  is 
immediately  relieved. 

ANAL  FISTULA. 

A  fistula  begins  in  an  abscess  in  the  cellular  tissue  around  the  anus. 
This  abscess  may  be  directly  under  the  skin  or  in  the  submucous 
tissue.  Instead  of  forming  an  exit,  the  pus  may  burrow  in  many 
directions,  making  honeycomb  ramifications.  The  abscess  may 
break  through  the  outer  skin  or  through  the  mucous  membrane, 
making  a  sinus.  The  longer  a  fistula  is  left,  the  more  does  it  burrow 
and  the  more  difficult  it  is  to  cure. 

A  simple  fistula,  as  a  rule,  extends  from  a  point  between  the 
internal  and  external  sphincters  a  distance  of  about  one  and  a  half 
inches  from  the  anus.  The  ends  of  the  fistulous  tract  are  usually 
small  openings,  while  the  space  between  may  be  long  and  tortuous. 
The  internal  opening  may  be  high  up  in  the  rectum  or  quite  low. 
The  fistulous  tract  is  usually  lined  with  a  pyogenic  membrane,  and 
pus  exudes  from  all  parts  of  its  ramifications.  The  classification  of 
fistula?  depends  upon  the  situation  of  their  openings. 

A  complete  fistula  opens  on  both  the  mucous  membrane  and  the 
cutaneous  surface.  A  complete  external  fistula  has  both  openings 
on  the  cutaneous  surface.  A  complete  internal  fistula  has  both 
openings  on  the  mucous  membrane.  A  blind  external  fistula  has 
one  opening  only — on  the  cutaneous  surface.  A  blind  internal 
fistula  opens  on  the  mucous  membrane  only. 

A  variety  of  complete  fistula  called  the  "horseshoe"  runs  from 
one  ischiorectal  fossa  to  the  other,  usually  with  one  external  and 
one  or  two  internal  openings. 

Whether  the  opening  be  internal  only  or  the  fistula  be  complete, 
the  watery  and  acrid  pus  which  contaminates  the  anal  margin  is  apt 
to  set  up  very  intense  pruritus,  and  thus  fistula  is  a  very  common 
cause  of  this  latter  condition.  The  itching  in  these  cases  is  also 
said  to  be  due  to  the  presence  of  minute  fecal  particles  caught  in  the 
granulations  of  the  fistulous  opening,  as  is  the  case  in  anal  fissure. 

Fistula?  frequently  follow  proctitis,  ulcers,  hemorrhoids,  and 
strictures.  The  inflammatory  process  penetrates  into  the  periproc- 
tal  tissues,  inducing  infiltration,  and  this  becomes  infected  so  that  an 
abscess  develops.  This  abscess  may  burrow  toward  the  rectum 
or  under  the  external  integument  of  the  anal  region,  perforating 
and  thus  establishing  a  fistula.     When  a  periproctal  abscess  rup- 


DISEASES  OF  THE  ANUS 

tures  into  the  rectum  only,  but  not  through  the  skin,  the  condition 
is  termed  an  incomplete  internal  fistula?.  Tubercular  fistula?  are 
very  frequent. 

Diagnosis. — The  most  reliable  diagnostic  measure  to  determine 
the  existence  of  a  complete  fistula  is  to  inject  peroxid  of  hydrogen 
into  the  external  opening.  If  the  fistula  is  incomplete,  tension  and 
pain  will  follow;  if  it  is  complete,  foam  will  escape  from  the  anus. 
The  internal  opening  in  a  complete  fistula  is  a  matter  of  very  con- 
siderable importance,  as,  unless  acquainted  with  its  usual  position 
(between  the  sphincters),  the  surgeon  may  fail  to  find  it.  Bismuth 
paste  or  carmin  injected  in  the  outer  opening  of  a  complete  fistula 
can  be  easily  seen  coming  through  the  internal  opening  (see  page  128). 
Under  certain  circumstances  fistula?  may  develop  without  the 
knowledge  of  the  patient,  whose  attention  is  aroused  only  when 
the  fistula,  external  or  internal,  discharges  purulent  matter  which 
moistens  and  soils  the  linen.  The  personal  discomforts  caused  by 
these  conditions  may  be  slight  at  the  time.  On  the  other  hand, 
very  considerable  inflammatory  phenomena  and  severe  pain  may 
be  induced  by  fistulse  retaining  their  contents.  Probing  the  fistula 
will  demonstrate  the  diagnosis  and  its  anatomic  nature  (complete 
or  incomplete  fistula). 

Treatment. — The  treatment  of  fistula  belongs  entirely  to  the 
surgeon.  Antiseptic  irrigations  rarely  cure.  Allingham  used  phenol 
with  some  success.  Rose  completely  cured  a  rectal  fistula  with  the 
use  of  carbon  dioxid.  A  current  of  the  gas  was  passed  into  the 
external  opening,  through  the  sinus  and  into  the  rectum,  filling  the 
bowel  to  its  full  capacity.  The  fistula  was  completely  and  entirely 
closed  and  healed  after  twelve  treatments. 

Pennington  reports  having  treated  many  cases  with  Beck's  bis- 
muth paste.  In  most  of  these  the  fistula?  were  located  in  the  pos- 
terior anal  quadrant,  and  apparently  were  not  very  extensive.  All 
of  them,  however,  communicated  with  the  rectum.  The  injections 
were  given  once  or  twice  a  week,  and  the  treatment  extended  over 
a  period  of  two  to  six  weeks.  The  apparent  results  were  eminently 
satisfactory. 

Complete  fistula?  should  be  opened  along  their  entire  extent  and 
packed.  Incomplete  fistula?  are  first  converted  into  complete  ones 
and  then  incised.  Abscesses  in  the  vicinity  of  the  rectum  require 
surgical  intervention.  Pains  and  inflammatory  conditions  are  to  be 
treated  by  rest  in  bed,  anodynes,  ice,  and  sitz  baths. 

FISSURE  OF  THE  ANUS, 

Fissures  of  the  anus  are  small  or  large  elongated  oval  tears  and 
linear  ulcers  at  the  margin  of  the  anus.  They  usually  consist  of  a 
solution  in  the  continuity  of  the  mucous  membrane,  with  a  yellow- 
ish-gray base,  and  secrete  scarcely  any  noticeable  pus.     Only  when 


PlSStlttE  OF  Till':  ANUS  N"''.) 

they  have  existed  for  some  time  and  attained  considerable  depth 
are  they  covered  with  a  mucoid  exudate.  The  linear  ulcers  occa- 
sionally penetrate  deep  into  the  muscle  and  expose  the  fibers  of  the 
external  sphincter.  Anal  fissures  may  he  very  long  and  spread  as 
far  up  as  the  mucous  membrane  of  the  rectum;  they  are  usually 
situated  in  the  median  line,  in  either  the  anterior  or  the  posterior 
commissure,  very  rarely  laterally. 

The  external  end  of  the  fissure  is  occasionally  the  site  of  a  small 
fleshy  prominence  or  "sentinel  pile,"  the  explanation  of  which 
we  owe  to  Ball.  He  has  clearly  shown  that  this  is  an  anal  valve 
of  Morgagni  which  has  been  dragged  down  by  the  pressure  of  hard- 
ened feces  and  has  left  in  its  track  a  longitudinal  ulcer  or  fissure 
extending  from  the  level  of  the  normal  ring  of  valves  to  the  outside 
of  the  anus,  wdiere  fecal  pressure  can  no  longer  exert  its  influence. 
In  such  cases  the  sentinel  pile  will  always  point  to  this  particular 
type  of  fissure  and  denote  the  true  nature  of  its  origin.  Fissures 
occasionally  give  rise  to  and  become  complicated  with  blind  internal 
fistula?,  due  to  burrowing  from  the  ulcerated  surface.  The  diagno- 
sis of  this  condition  must  be  made  by  observing  the  exudation  of  a 
definite  amount  of  pus  and  by  the  use  of  a  probe. 

The  cause  of  these  tears  cannot  always  be  elicited.  Chronic 
constipation  with  very  hard  feces  contributes  to  their  development, 
especially  when  the  anus  is  very  tight  and  the  anal  skin  tender. 
They  may  also  be  caused  mechanically,  especially  from  the  use  of 
toilet  paper.  Fissures  make  their  appearance  as  secondary  ulcers 
in  consequence  of  gonorrhea,  syphilis,  tuberculosis,  and  hemor- 
rhoids.    They  occur  more  frequently  in  the  female  than  in  the  male. 

Symptoms. — Clinically,  anal  fissure  is  characterized  first  by  pains, 
which  are  particularly  marked  during  the  passage  of  feces  through 
the  torn  anus.  Severe  pain  frequently  occurs  in  the  fissure  even 
after  defecation,  evoking  reflex  spasms.  The  pains  may  radiate 
toward  the  bladder,  the  genitals,  and  the  thighs.  Even  with  minute 
fissures  the  pain  is  often  intolerable.  Hemorrhage  from  the  fissure 
is  frequent  during  defecation.  The  patients  are  inconvenienced 
extremely  by  these  pains;  they  anxiously  refrain  from  going  to 
stool,  and  even  avoid  the  expulsion  of  flatus.  The  symptoms  are 
least  apparent  during  bodily  rest.  Pruritus  is  a  common  symptom 
of  fissure  and  may  be  the  only  symptom  which  induces  the  patient 
to  seek  advice. 

The  diagnosis  is  easily  made  by  a  careful  inspection  of  the  anus. 
It  is,  however,  essential  to  smooth  out  the  anus  entirely,  as  small 
fissures  are  often  deeply  concealed  in  the  folds  at  the  mucocutaneous 
junction. 

Treatment. — A  good  deal  can  be  accomplished  by  prophylaxis 
in  persons  who  have  previously  been  afflicted  with  fissures.  Appro- 
priate treatment  of  the  chronic  constipation  and  extreme  cleanliness 
of  the  anus  will  do  much  as  preventive  measures.  Such  persons 
should  avoid  the  exertion  of  much  pressure  during  defecation. 


S60  DISEASES  OF  THE  ANUS 

To  bring  about  the  healing  of  a  recent  fissure  as  quickly  aS 
possible  it  is  best  to  place  the  patient  in  bed  for  at  least  one  week, 
retard  the  defecation  artificially  by  prescribing  a  liquid  diet,  and 
administer  ten  drops  of  the  tincture  of  opium  three  times  a  day. 
The  fissure  itself  should  be  covered  with  a  dusting  powder  (xero- 
form,  iodoform,  anesthesin,  orthoform,  chloretone),  and  all  unneces- 
sary manipulations  of  the  anus  avoided.  Eight  days  later  a  large 
dose  of  castor  oil  is  given.  The  patients  should  go  to  stool  only 
when  they  have  the  sensation  that  the  fecal  matter  has  become 
liquid.  To  effect  a  complete  cure,  it  is  important  that  the  passage 
of  feces  be  suspended  for  fully  eight  days.  Frequently,  however, 
this  object  is  not  attained  in  eight  days,  and  in  such  cases  the  treat- 
ment must  be  repeated  once  or  twice. 

An  alternative  method,  recommended  by  a  number  of  authors, 
seems  to  be  quite  successful.  Here  defecation  is  not  interrupted; 
on  the  contrary,  it  is  increased  by  a  chemically  active  diet  and  by 
mild  purgatives  (castor  oil,  mineral  salts,  bitter  saline  waters)  or 
oil  enemata  (|  pint  at  night).  At  the  same  time  rest  in  bed,  if 
possible,  is  very  beneficial.  The  patient  during  this  time  may  be 
on  full  diet.  Before  every  defecation  a  small  wad  of  absorbent 
cotton  saturated  with  a  5-  to  10-per-cent.  solution  of  cocain  is 
inserted  into  the  rectum;  the  cotton  remains  there,  to  be  expelled 
painlessly  with  the  pending  stool.  The  care  of  the  anus  must  be 
very  thorough  after  every  act  of  defecation,  in  order  to  avoid 
stretching  or  irritation  of  the  fissure.  One  of  the  best  applications 
is  a  suppository  of  opium  0.02  Gm.  (f  grain)  and  extract  of  bella- 
donna 0.01  Gm.  (|  grain).  By  these  methods  it  is  possible  to  bring 
about  painless  evacuations  and  to  avoid  unnecessary  irritation  of 
the  fissure,  thus  accelerating  the  process  of  healing. 

But  in  case  of  failure  frequent  cauterization  with  pure  silver 
nitrate,  10-per-cent.  nitrate-of-silver  solution,  or  pure  ichthyol  is 
beneficial.  Cauterization  should  never  be  practiced  without  the 
previous  induction  of  local  anesthesia.  The  fissure  can  be  easily 
anesthetized  by  means  of  a  wad  of  absorbent  cotton  saturated  with 
a  2-  to  5-per-cent.  solution  of  cocain  and  allowed  to  remain  in  the 
anus  a  few  minutes.  Without  local  anesthesia  intolerable  pains 
follow  the  cauterization.  The  fissure,  after  cocainization,  may  be 
energetically  brushed  twice  daily  with  pure  ichthyol;  or  it  can  be 
first  dusted  with  anesthesin  or  orthoform  and  then  painted  with 
ichthyol.  This  is  to  be  done  daily  for  one  week  and  then  every 
other  day  until  the  ulcer  is  healed.  If  there  has  been  much  spasm 
of  the  sphincter,  Tuttle  smears  the  parts  with  an  ointment  com- 
pound, as  follows: 

Gm.  or  Co. 
1^ — Unguenti  stramonii, 

Unguenti  belladonna?, 

Unguenti  hy os cy ami     .      .      .      .   aa     15 10  5iv 

Misce  et  ft.  unguentum. 
Sig. — Apply  freely. 


FISSURE  OF   THE  ANUS  Mi] 

This  has  always  seemed  to  relieve  the  spasm,  and  controls  the 
pain  resulting  from  the  application  of  the  ichthyol.  When  the 
fissures  arc  small,  a  camel-hair  brush  saturated  with  pure  ichthyol 
may  be  introduced  into  the  anus  without  cocain;  the  anus  then 
contracts  rellexly  and  presses  the  ichthyol  into  all  its  recesses  and 
folds.  Instead  of  this,  when  the  patients  arc  very  sensitive,  an 
ichthyol  ointment  has  been  found  useful: 

Gin.  or  Cc. 
1$ — CocaintP  hydrochloridi, 

Extract!  belladonnae      .      .      .      .   aa       0  06  gr.  j 

Ichthyoli 6|0  5iss 

Misce, 
Sig. — To  be  introduced  warm  by  means  of  a  sound  wrapped  with  absorbent 
cotton. 


A  superficial  cauterization  may  also  be  induced  by  a  Paquelin 
thermocautery;  it  is  essential,  however,  to  cocainize  previously  and 
to  apply  afterward  the  following  ointment: 

Gm,  or  Cc. 

1$ — Acidi  borici 3(0  gr.  xlv 

Cocaina? 1 1 0  gr.  xv 

Adipis  lanae  hydrobi 25 1 0  5vj 

Petrolati 6 1 0  5iss 

Misce  et  ft.  unguent um. 

Sig. — Apply. 

The  entire  region  of  the  anus  must  be  repeatedly  covered  with 
this  ointment. 

For  hemorrhage,  epinephrin  can  be  used.  Epinephrin  supposi- 
tories have  a  cooling,  hemostatic  effect,  and  can  be  employed  with 
gratifying  results.     Epinephrin  ointment  also  is  available. 

Cool  sitz  baths  and  local  applications  are  valuable  adjuvants 
to  the  treatment  of  the  fissure. 

It  is  found  that  the  wearing  of  a  hemorrhoidal  pessary  for  ten 
to  fourteen  days  (daily  one  or  two  hours)  is  capable  of  relieving 
the  pains  and  will  often  bring  about  a  cure  (Figs.  149  and  150). 

Doctor  Bensaude,  of  Paris,  highly  recommends  the  high-frequency 
current  in  every  case  of  fissure.  He  introduces  the  electrode  into 
the  rectum  and  allows  the  current  to  pass  through  for  five  minutes 
at  each  seance.  The  patient  receives  a  treatment  every  day  until 
the  pain  is  relieved  and  then  every  other  day.  Recovery  usually 
takes  place  in  two  to  three  weeks. 

Dilatation  or  divulsion  of  the  anal  sphincters  often  brings  about 
complete  recovery.  This  operation  may  be  done  with  a  bivalve 
speculum,  but  better  with  the  fingers.  The  two  first  fingers  are 
gently  inserted  into  the  rectum  after  the  patient  has  been  fully 
anesthetized.  The  anus  is  then  thoroughly  stretched,  antero- 
posterior!^- first,  then  laterally.     This  is  repeated  until  all  spasm  has 


DISEASES  OF  THE  ANUS 

disappeared  and  the  canal  remains  patulous.     The  operation  must 
not  be  overdone,  or  it  may  lead  to  permanent  relaxation. 

Should  these  methods  fail  to  bring  about  a  recovery,  surgical 
intervention  is  necessary.  Surgical  methods  of  treatment  consist 
in  the  superficial  and  deep  section  of  the  fissure,  or  completely 
cutting  the  external  sphincter  muscle  in  such  a  way  that  its  fibers 
are  divided  transversely. 


COMPARATIVE  SCALES  OF  THE  METRIC  AND 
APOTHECARIES'  WEIGHTS  AND  MEASURES. 


Fluid  Measure. 

Apothecaries'  Weight. 

Gm.  or  C 

Jc. 

Ounces.     Minims. 

Ounces.        Grains. 

1000 

= 

33 

+  390.6 

=        ; 

32  +     72.4 

500 

= 

16 

+  435. 

3 

= 

16  +     36.2 

250 

= 

8 

+  217. 

.7 

= 

8  +     18.1 

100 

= 

3 

+  183. 

1 

= 

3  +  103.2 

50 

= 

1 

+  331. 

5 

= 

1   +  291.6 

25 

= 

405 

.77 

= 

385.8 

10 

= 

162 

.31 

= 

154.3 

5 

= 

81 

.16 

= 

77.2 

1 

= 

16 

.23 

= 

15.4 

Fluid  Measure. 

Metric. 

2 

pints 

= 

946 

,358  Gm. 

or  Cc. 

1 

pint 

= 

473 

.179  Gm. 

or  Cc. 

i 

2 

pint 

= 

236 

.590  Gm. 

or  Cc. 

3 

ounces 

= 

88 

,721  Gm. 

or  Cc. 

2 

ounces 

= 

59 

,147  Gm. 

or  Cc. 

1 

ounce 

= 

29 

,573  Gm. 

or  Cc. 

60 

minims 

= 

3 

.697  Gm. 

or  Cc. 

INDEX. 


Aakon's  abdominal  bandage1,  575 
improved  stomach  tube,  68-70 
sign  of  chronic  appendicitis,  773 

of  gastroenteroptosis,  5(i5 
stomach  tube  and  bulb,  69 
Abdrrhalden   reaction   in    gastric   car- 
cinoma, 544 
Abdominal  angina  from  arteriosclerosis, 
526 
bandage,  Aaron's,  575 

Rose's  adhesive,  578 
bandages,  575-578 

indications  for,  575,  605 
belt,  578 
corsets,  580 
massage,  212,  214 
Abscess  of  lips,  334 

retropharyngeal,  348 
of  tongue,  324 
tubercular,  of  pharynx,  348 
Absorption  of  aqueous  and  saline  solu- 
tions, 61 
of  carbohydrate,  61  . 
of  cellulose  and  hemicellulose,  61 
of  fat,  60 

in  large  intestine,  61 
of  protein,  60 
in  small  intestine,  60 
Absorptive  power  of  stomach,  56 

Giinzburg's    method     of 
testing,  89 
Acetylsalicylic    acid,    occasional    oral 

effects  of,  301 
Achalasia,  394 

Achlorhydria,    carbohydrate   digestion 
in,  85 
hemorrhagica  gastrica,  464 
Achroodextrin,  50 
Achylia  gastrica,  95,  464 

carcinoma  and,  464 
cholelithiasis  and,  464 
congenital,  465 
connective  tissue  in  stools  of, 

674 
etiology  of,  465 
pathology  of,  465 
secondary,  466 
senilis,  464 

stomach  contents  in,  95 
symptoms  of,  465 
test-diet  stool  findings  in,  131 


Achylia  gastrica,  treatmenl  of,  dietary, 
466 
by  lavage,  471 
medicinal,   Hi!) 

antiseptic,  470 
hydrochloric  acid,469 
pancreatin,  469 
papain,  469 
stomachics,  469 
physical,  472 
with  mineral  waters,  472 
Acid  secretion  after  milk,   meat  and 

bread,  53 
Acidity  of  filtered  and  unfiltered  gastric 
contents,  78 
of   stomach    contents,    Benedict's 
effervescence  test  for, 


dimethylamidoazobenzol 

test  for,  75 
Friedrich's  test  for,  89 
gauze  test  for,  89 
gelatin  test  for,  84 
Giinzburg's  tests,  76,  89 
phenolphthalein  test,  79 
quantitative  test,  89 
Sahli's  desmoid  test,  90 
thread  test  for,  88 
Topfer's   test    (quantita- 
tive), 80 
Acidol  in  gastric  diseases,  260 
Acidosis  in  typhoid  fever,  716 
Acids  in  hyperchlorhydria,  432 
Acorn  cocoa,  194 
Actinomycosis  of  esophagus,  361 
in  man,  316 
of  salivary  glands,  329 
treatment  of,  316 
Activators  of  digestion,  53 
Adamantoma  of  maxilla?,  345 
Adenocarcinoma  of  stomach,  540 
Adenoma,  555 

of  mouth,  340 
Adhesions,  gastric  massage  for,  208 
intestinal,  Roentgen  fluoroscopy  in 
diagnosis  of,  148 
Adrenalin  (epinephrin)  in  anal  fissure, 
861 
in  bleeding  hemorrhoids,  823 
in  diagnosis  of  pancreatic  insuffi- 
ciency, 626 
in  esophageal  corrosions,  358 
in  dysenteric  pains,  725,  726,  727 


864 


INDEX 


Adrenalin  in  gastric  hemorrhage,  271, 
519 

irrigations  in  dysentery,  726 

in  nervous  diarrhea,  682 

in  pylorospasm,  411 

in  vomiting  of  pregnancy,  404 
Aerophagy,  401 

diagnosis  of,  402 

flatulence  and,  701 

hyperalimentation  in,  402 

psychic  treatment  of,  402 

stomach  tube  in,  402 
Agar  in  constipation,  184,  662 

tannin,  278 

tubes  for  estimation  of  duodenal 
enzymes,  102 
Akerhielm's  rectal  friction  treatment 

of  chronic  constipation,  229 
Akoria,  416 
Albuminuria  in  acute  intestinal  catarrh, 

636 
Albumoses,  54 

Alcohol  content  of  artificial  foods,  189, 
190 

effect  of,  on  gastric  digestion,  168 
secretion,  267 

in  food  cures,  572 
Aleuronat  flour,  191 
Alimentary  catarrh,  635 

hypersecretion,  447 
Alimentation,  duodenal,  500.     See  also 
Diet  and  Hyperalimentation. 

in  esophageal  stricture,  372 

in  gastric  ulcer,  500 

in  hepatic  cirrhosis,  594 
Alizarin  in  computing  court  ined  HC1, 

81, 

Alkali  carbonated  waters,  253 
carbonates,  264 
chlorin  waters,  252 
earths,  264 

poisoning,  fatality  of,  357 
Alkalis  and  alkaloids  in  hyperchlorhy- 
dria,  436,  437,  438 
in  gastric  disease,  263,  265 
Alveolar  processes,  affections  of,  331 

sarcoma,  346 
Amebic  dysentery,  emetin  in  treatment 
of,  723 
erne  tin-bismuth  iodid  in  treat- 
ment of,  724 
Aminoacids,  60 

Ampoules  of  aseptic  solutions,  581 
Amyl  nitrite  as  a  gastric  sedative,  268 
Amylodextrin,  50 
Amylopsin,  58 

Anal  dilatation  in  rectal  stricture,  839 
in  spastic  constipation,  672 
fissure,  858 

cauterization  of,  860,  861 

defecation  in,  860 

diagnosis  of,  859 

diet  in,  860 

dilatation  of  sphincters  in,  861 

electricity  in,  861 


Anal  fissure,  epinephrin  in,  861 
etiology  of,  859 
hemorrhage  of,  861 
hemorrhoidal  pessaries  in,  861 
ichthyolin,  860,  861 
"sentinel  pile"  of,  859 
silver  nitrate  in,  860 
sphincter  spasm  in,  860 
surgery  in,  862 
symptoms  of,  859 
treatment  of,  859 
fistula,  857 

antecedents  of,  857 
bismuth  paste  in,  858 
complete,  857 
diagnosis  of,  858 
"horseshoe,"  857 
hydrogen  peroxid  in,  858 
simple,  857 
surgery  of,  858 
symptoms  of,  858 
plugs,  856 
refrigerator,  824 
Analysis,  fractional,  of  gastric  secretion, 
78 
quantitative,  of  stomach  contents, 
76 
Anastalsis  of  intestine,  63 
Anemia,  ground  itch,  811,  813 
from  hemorrhoids,  822 
of  hookworm  disease,  811 
in  intestinal  toxemia,  689 
miner's,  806 

pernicious,  sore  mouth  in,  302 
urobilin  and  urobilinogen  in,  110 
Anesthesin  as  a  gastric  anodyne,  270 
Aneurysm,  racemose,  of  mouth,  336 
Angina,  abdominal,  52  o 

Ludwig's,  3b0 
Angioma,  cavernous,  of  mouth,  336 
Anguillula  infection,  symptoms  of,  816 
treatment  of,  816 
intestinalis,  815 
Animal  parasites  in  esophagus,  361 
in  intestine,  794 
in  mouth,  320 
protein  preparations,  187 
Ankylostoma  duodenale,  806,  807,  808, 

809.     See  Hookworm. 
Anodynes,  gastric,  270 
Anorexia,  electricity  in,  215 
nervous,  416 

treatment  of,  417 
Anoscope,  Hirschman's,  830 
Anthrax  pustule,  334 
Antidysenteric  serum  in  epidemic  dys- 
entery, 727 
Antifermentative  diet,  181 
Antifermentatives  in  intestinal  diseases, 

279 
Antilytic  serum  in  gastric  ulcer,  506 
Antiperistalsis  of  intestine,  63 
Antiputrefactive  diet,  174 
Antipyrin,  occasional  oral  effects  of,  301 
Antiseptic  diet,  174,  689 


INDEX 


865 


Antiseptic  mouth  washes,  306 

value  of  milk.  171 
Antiseptics  in  gastric  diseases,  272 

in  intestinal  diseases,  279 
Antitryptic   reaction   in   gastric  carci- 
noma, 54  1 
Anus,  artificial,  729 

diseases   of,   851.     S<<    Anal,   and 

Pruritus. 
fissure  of,  V|S 
Aperient  effect  of  sugars.  2S-1 

value  of  fruit-.  28  1 
Aphtha;,  307 
chronic,  ">(ls 
treatment  of,  308 
tropica^,  308 
Appendicitis,  76*3 
acute,  767 

bacteria  of,  767 
Blaisdell's  sign  of,  770 
Blunibcrg's  sign  of,  770 
cutaneous    hvperesthesia    in, 

769 
diagnosis  of,  147,  769 
diet  in,  777 
etiology  of,  767 
ice  in,  776 

ingestion  of  water  in,  774 
intestinal  irrigation  in,  774 
leukocytosis  in,  775 
Meltzer's  sign  of,  770 
Murphy  drip  in,  774,  778 
non-surgical  treatment  of,  776 
Ochsner's  method  of  treating. 

774 
operative  mortality  of,  773 
opium  in,  778 
from  pinworms,  767 
point  of  pain  in,  770 
purgation  in,  776 
sigmoidal  disease  and,  786 
.  symptoms  of,  768 
time  of  operation  in,  774 
treatment  of,  773 

internal  medical,  776,  777 
surgical,  773,  777,  778 
vaccine,  780 
as  a  cause  of  nervous  dyspepsia 

419 
cecal  tuberculosis  and,  741 
cecum  mobile  and,  770 
chronic.  771 

Aaron's  sign  of.  i  73 
Bastedo's  dilatation  test  for, 

773 

cecal  distention  test  for,  i  <2 

diagnosis  of,  772 

diet  in  non-operative  cases  of, 

779 
drinking  cures  in,  779 
Morris'  pressure  point_in,  773 
movable  kidney  and,  768 
Rovsing's  sign  of,  772 
Rutkevich's  sign  of,  772 
symptoms  of,  771 
55 


Appendicitis,  chronic,  treatment  of,  79 

destructive.  768 

duodenal  ulcer  and,  705 
larval  a,  772 

perisigmoiditis  and.  -  s"),  <*•' 
phylacogens  in,  780 
relation  of  other  diseases  to,  lUl 
visceral  ptosis  and.  768 
Appendicostomy  in  chronic  dysentery, 

729 
Appendicular  inflammation,  767 
Appendix  vermiformis,  visualization  ot 

by  roentgenography,  187 
Aptyahsm,  330  . 

Aqueous  solutions,  absorption  ot,  01 
Argvrosis,  301  . 

Aromatic  products  of  intestinal  putre- 
faction, 686 
Arsphenamine,  534 

in  amebic  dysentery,  725 
Arteriosclerosis,  528 

abdominal  angina  from,  o28 

antisclerosin  in,  532 

diagnosis  of,  530 

etiology  of,  528 

gastric  hemorrhage  trom,  ozs 

ulcer  from,  528 
iodid  medication  in,  532 
pathology  of,  529 
results  of,  528 
symptoms  of,  529 
treatment  of,  530 
hygienic,  531 
medicinal,  531 
Trunecek's  serum  in,  532 

Artificial  anus,  729 

food  preparations,  177,  187 

comoared  with  milk,  l»y 
Ascaris   lumbricoides,    800,    801.     See 

also  Round  worm. 
Ascites,  hepatic  cirrhosis  and,  o92 
paracentesis  in,  595 
potassium  bitartrate  in,  595 
Aspiration  method  of  obtaimng  stom- 
ach contents,  68,  206 
stomach  tube,  Chase's,  206 
Asthenia  universalis  congenita,  558 
Astringent  food  and  drink,  177 
Astringents  in  hyperchlorhydna,  4do 

in  intestinal  diseases,  172,  276 
Atonic  constipation.    See  Constipation. 
Atonv  of  esophagus,  386  . 

gastro-intestinal,  pilocarpus  m,  6\M 
of    stomach,    95,    473.     See    also 
Motor  insufficiency. 
faradization  in,  215 
high-frequencv  current  in,  21 J 
shown    by    roentgenography, 
140 
Atrophy  of  liver,  598 
Atropin  as  an  eyacuant,  283 

in  gastric  diseases,  2/1,  oy^s,  *<so, 

441 
in  ileus,  754 
in  vagotonia,  390,  392 


866 


INDEX 


Atropin  vs.  pilocarpin,  271 

Atwaters  table  of  food  values,  153-155 

Atzperger  s  rectal  refrigerator,  848 

Auerbach's  plexus,  63 

Autolavage,  201 

Autonomic  nervous  system,  388 

Awltail,  803 


B 


Bacilli,  Boas-Oppler,  in  diagnosis,  92 
intestinal,  that  will  not  grow  on. 

gelatin,  177 
tubercle,    demonstrated   in    feces, 
122 
Bacteria  in  feces,  118 

in  intestine,  122,  686 
in  mouth,  289,  700 
pathogenic  affinities  of,  293 
transmutation  of,  291,  684 
Bacterial  excitants  of  intestinal  peris- 
talsis, 62 
fermentation,  699 
growth  in  the  intestine,  686,  699 
preparations  from  feces,  118 
putrefaction,  700 
vaccines  in  appendicitis,  780 

in  chronic  intestinal  catarrh, 

649 
in  enteritis  membranacea,  656 
in  gastric  ulcer,  506 
in  pruiitus  ani,  856 
in  ulcerative  colitis,  735 
Bacteriology  of    bile    ducts   and   gall 
bladder,  607 
of  duodenum,  107 
Ball's  operation  in  pruritus  ani,  857 
Bandage,  abdominal,  Aaron's,  575 
adhesive  plaster,  578 
Priessnitz,  250 
Barium  or  bismuth  in  roentgenography, 

135 
Bastedo's   dilatation   test   for   chronic 

appendicitis,  773 
Baths  in  cirrhosis  of  liver,  594 
cold  entire  pack,  248 
half,  248 

indications  for,  249 
medicated,  249 
mineral,  256 
mud,  257 
prolonged,  249 
rub-oft,  247 
sea,  256 

warm  entire  pack,  249 
wet  rub,  247 
Bead  test  for  gastro-intestinal  motility, 

129 
Beans  in  diet  of  gastric  patients,  167 
Beef  tea,  161,  194.     See  Bouillon  cubes. 
Beets  in  gastric  diseases,  166 
Belladonna  in  gastric  diseases,  271 

in  vagotonia,  392 
Belt,  adhesive-plaster,  578 


Belt  sign  for  abdominal  bandage,  575 
Benedict's  effervescence  test  for  gastric 

acidity,  88 
Benzidin  test  for  occult  blood,  123 
Benzyl  benzoate  in  amebic  dysentery, 

724 
Beverages  in  constipating  diet  of  intes- 
tinal diseases,  172 
Bile,  58 

acids,  58 

constituents  of,  58 
daily  secretion  of,  58 
duct,  agglutination  of,  610 

obstruction,  indications  of,  109 
ducts,  dilatation  of,  615 
diseases  of,  607 
drainage  of,  104 
hemorrhage  into,  614 
neoplasms  of,  614 
diagnosis  of,  615 
symptoms  of,  615 
treatment  of,  615 
parasites  of,  616 
in  duodenal  contents,  significance 

of,  109 
enemata,  226 
function  of,  58 
pigments,  58 

in  stool,  122,  637 
secretion,  HC1  and,  259 
in  stomach,  66 
Bilharzia,  817 

Biliary  calculi  from  trematodes,  818 
Bilirubin  in  feces,  significance  of,  122, 

646 
Bismuth  in  gastric  diseases,  265,  266 
in  roentgenography,  137,  138,  139 
salts,  265 
stomatitis,  300 
Bitter  waters,  254 
Bitters,  266 
Blisters  from  hot  applications,  how  to 

avoid,  250 
Blood  in  feces,  demonstration  of,  123 
occult,  in  feces,  benzidin  test  for, 
123 
phenolphthalein  ring  test 

for,  124 
significance  of,  123 
spectroscopic      detection 
of,  123 
in  intestinal  tuberculosis,  133, 
738 
in  stomach  contents,  66,  86 

Weber's  guaiac  test  for, 
86 
test  in  diagnosis  of  duodenal  ulcer, 
709 
Blood-iron  preparations,  188 
Blood-sugar  in  gastric  carcinoma,  545 
Blumberg's  sign  of  acute  appendicitis, 

770 
Boas'  extra-anal  treatment  for  hemor- 
rhoids, 827 
rectal  electrode,  231 


INDEX 


867 


Boas'  stomach  electrode,  210 

test  breakfast,  07 
Boas-Oppler  bacillus  in  gastric  carci- 
noma, 92 
Bothriocephalua  latus,  794,  797 
Bougie,  cannula  and,  371 

C 'rede's,  838 

esophageal,  350 

Wales,  733 
Bouillon  cubes,  value  of,  195 
Bread  in  gastric  diseases,  105 

value  of  different  kinds  of,  105 
Breakfast,  test,  67 
Bromid  salivation,  301 
Bromids  in  gastric  diseases,  209 
Buccal  fundus,  carcinoma  of,  344 

phlegmons  of,  330 
Bulimia,  415 

electricity  in,  215 

treatment  of,  410 
Burns  of  esophagus,  357 

of  mouth,  304 
Butler  as  an  article  of  diet,  152 
Buttermilk  in  gastric  disease,  104 

belly,  811 


Calculi  of  pancreas,  033 

salivary,  327 
Calomel  as  an  intestinal  antiseptic,  280 

as  a  purgative,  285 
Caloric  requirements  in  health,  150 

value  of  foods,  151 
Cancer.     See  Carcinoma. 
Cancorin,  550 
Cancrodin,  550 
Cannabis  indica  as  a  gastric  sedative, 

209 
Cannula,  esophageal,  371 
Capsule  method,  double,  of  administer- 
ing HC1,  200 
Caput  medusae,  592 
Carbohydrate  absorption,  01 

digestion  in  achlorhydria,  85 
in  hyperchlorhydria,  85 
in  stomach,  85 
fermentation,    organisms    respon- 
sible for,  181 
preparations,  192 
Carbohydrates  in  chronic  pancreatitis, 
028 
in  food  cures,  572 
hydrochloric  acid  and,  030 
Carbon  dioxid  enemata,  220 
Carcinoma  of  bile  ducts,  614 
diagnosis  of,  015 
symptoms  of,  015 
treatment  of,  015 
of  buccal  fundus,  344 
of  cardia,  543 

treatment  of,  551 
of  colon,  704 

diagnosis  of  704 


Carcinoma  of   colon,   roentgenography 
in,  145 
symptoms  of,  704 
treatment  of,  705 

of  duodenum,  762 

diagnosis  of,  763 

symptoms  of,  763 

types  of,  763 
of  esophagus,  362 

alimentation  in,  372 

diagnosis  of,  363 

predisposing  factors  in,  363 

radium  in,  364 

roentgenography  in,  138 

symptoms  of,  363 

treatment  of,  ameliorative,373 
by  radiation,  373 
surgical,  372 
of  gall  bladder,  614 

diagnosis  of,  615 
symptoms  of,  615 
treatment  of,  615 
of  ileum,  764 
of  intestine,  761 

in  England  and  Japan,  761 

heredity  of,  762 

incidence  of,  761 

location  of,  761,  762 

pathology  of,  762 

in  Prussia,  761 

roentgenography  in,  764 

statistics  on  operative  treat- 
ment of,  765 

test-diet  stool  findings  in,  134 

treatment  of,  765 

in  Vienna,  761 
of  jejunum,  704 
of  lips,  342 
of  liver,  000 
of  malar  mucosa,  344 
of  maxillae,  340 
of  mouth,  342 

relation  of  leukoplakia  to,  342 
of  palate,  344 
of  rectum,  832 

complications  of,  833 

diagnosis  of,  833 

inoperable,  834 

radium  in,  834 

symptoms  of,  832 

treatment  of,  833 

surgical,  833,  834 
symptomatic,  834 
and  sarcoma  of  stomach,  differen- 
tiation of,  554 
of  stomach,  97,  537 

adenoid,  540 

age  incidence  of,  539 

beginning,  543 

blood-sugar  tolerance  test  for, 
545 

Boas-Oppler  bacilli  in,  543 

cardiac  stenosis  in,  552 

colloid,  540 

complications  of,  541 


868 


INDEX 


Carcinoma  of   stomach,   cytodiagnosis 
of,  87 
development  of,  537 
diagnosis  of,  86,  542 
differential,  554 
gelatinous,  540 
heredity  in,  539 
incidence  of,  537 
medullary,  540 
occult  hemorrhage  in,  543 
pathology  of,  539 
predisposing  factors  in,  537 
roentgenography  in,  142 
scirrhous,  540 
serologic  reactions  in,  543 
Abderhalden,  544 
antitryptic,  544 
hemolytic,  543 
miostagmin,  544 
stomach  contents  in,  543 
symptoms  of,  541 
territorial  incidence  of,  537 
test-diet  stool  findings  in,  131 
tests  for,  86.     See  also  Sero- 
logic reactions,  above, 
cytodiagnostic,  87 
Gluzinski's,  88 
glycyltryptophan,  87 
Salomon's,  86 
Wolff-Junghans,  87 
treatment  of,  546,  551 
dietetic,  547,  551 
internal,  546 
by  lavage,  548 
medicinal,  549 
arsenic,  550 
autolysin,  550 
cancorin,  550 
cancrodin,  550 
condurango,  549 
methylene  blue,  550 
mineral  waters,  549 
physical,  549 
radium  in,  550 
Roentgen  ray  in,  550 
of  tongue,  342 
of  uvula,  344 
Carcinomata  in  male  and  female,  761 
Cardiac  carcinoma,  543 
dilator,  Myer's,  397 
Cardialgia,  410 
Cardiospasm,  393 
diagnosis  of,  394 

fluoroscopic,  137 
oil  cure  for,  397 
prognosis  of,  395 
symptoms  of,  394 
treatment  of,  396 

by  dilatation,  397 
electrical,  298 
psychic,  396 
surgical,  398 

with  sounds  and  bougies,  397 
Carlsbad  waters,  253,  264 

in  catarrhal  jaundice,  611 


Carlsbad  waters  in  cholelithiasis,  620 

Carmin  test  of  intestinal  motility,  128 

Carringen,  188 

Castor  oil  as  a  purgative,  286 

Catalytic  action  of  enzymes,  53 

Cataplasms,  250 

Catarrh,  alimentary,  635 

gastric  and  intestinal,  furruginous 
waters  in,  254.     See  also  Intes- 
tinal catarrh. 
Cathartics  by  enema,  227 
Cauterization  in  diseases  of  mouth,  298 
Cavernous  angiomata  of  mouth,  336 
Cecal  distention  test  for  chronic  appen- 
dicitis, 772 
Cecum  mobile,  146,  560 

Roentgen-ray  diagnosis  of,  146 
tuberculosis  of,  740 

appendicitis  and,  770 
symptoms  of,  740 
treatment  of,  741 
volvulus  of,  diagnosed  by  Roent- 
gen ray,  147 
Cells  of  stomach  and  their  function,  54 
Cellulose  absorption,  61 

behavior  of,  in  intestine,  183 
bread,  184 

in  cauliflower,  spinach,  and  cab- 
bage, 183 
in  diet,  179 
digestibility  of,  183 
digestion  of,  61,  183 
ferment,  678 

hemicellulose  and,  61,  184 
as  a  laxative,  184 
Centenarians  in  Bulgaria  and  Germany, 

165 
Cervical  laceration,  nervous  dyspepsia 

and,  419 
Charcoal  test  of  intestinal  motility,  128 
Chase's  aspiration  tube,  206 
Cheeks,  affections  of,  333,  335 
Cheese  in  gastric  diseases,  165 
Cheilitis,  acute,  334 
chronic,  334 
exfoliativa,  334 
glandularis,  334 
Chemical  examination  of  feces,  116 

of  stomach  contents,  74 
Childbirth,  gastroenteroptosis  and,  557, 

581 
Chloral  hydrate  as  a  gastric  sedative, 

269 
Chloroform  as  a  gastric  anodyne,  270 

water  irrigations,  227 
Chlorophyl  test  of  gastric  motility,  91 
Chocolate,  digestibility  of,  169 

"Kraft,"  194 
Cholangitis,  607 

cholecystitis  and,  diagnosis  of,  610 

etiology  of,  607 

hemocones  in,  611 

pathology  of,  607 

sequelae  of,  609 

suppurative,  etiology  of,  613 


I\  DEI 


869 


( iholangit  is,  suppurative,  pathology  of, 
613 
symptoms  of,  <'>  1  1 
treatmenl  of,  til  I 
symptoms  of,  608 
treatment  of,  61 1 

antipruritic,  613 
Carlsbad,  till 
diet,  613 
glycerin,  til 2 
magnesium  sulphate,  612 
( Jholecystitis,  tit  is.  See  also  Cholangitis. 

adhesions  from,  til  1 
anatomic  effects  of,  608 

diagnosis  of,  tilt),  til!) 
duodenal  contents  in,  109 

ulcer-and,  70S 
nervous  dyspepsia  and,  419 
pathogenesis  of,  ti()7 
symptoms  of,  60S 
treatment  of,  611 
Cholelithiasis,  616 
calomel  in,  552 
Carlsbad  cure  for,  620 
cholagogues  and  antiseptics  in,  621 
diagnosis  of,  618 
drainage,  non-surgical,  in,  621 
duodenal  ulcer  and,  708 
etiology  of,  617 
heredity  in,  617 
HC1  secretion  in,  S5 
nervous  dyspepsia  and,  419 
roentgenography  in,  150,  618 
symptoms  of,  618 
treatment  of,  619 
dietetic,  620 
medicinal,  621 
mineral  water,  620 
by  non-surgical  drainage,  621 
surgical,  622 
Cholemia,  610 

Cholera  morbus,   638,   642.     See  also 
Intestinal  catarrh, 
hypodermoclysis  in,  643 
pain  and  vomiting  in,  643 
sea-water  in  treatment  of,  642 
nostras,      638.       See      Intestinal 
catarrh,  acute. 
Cholesterol,  59 
Cholesterolemia,  617 
Chologen  in  cholelithiasis,  621 
Chondroma  of  maxillae,  345 

of  mouth,  336 
Chondrosarcoma,  maxillary,  346 
'Chyme,  rate  of  movement  of,  64 
Cirrhosis  of  liver,  atrophic,  590 
etiology  of,  590 
levulose  test  in,  593 
pathology  of,  590 
phthalein  test  in,  593 
prognosis  of,  593 
symptoms  of,  591 
tests  for  lipase  in,  592 
treatment  of,  594 
medicinal,  594 


Cirrhosis  of  liver,   atropine,    treatment 
of,  surgical,  595 

urobilin  test  in,  593 

mi  course  of  ot  her  diseases,  598 

from  trematodes,  818 
hypertrophic,  596 

in  bronze  diabetes,  597 
diagnosis  of,  597 
etiology  of,  .")<)() 
prognosis  of,  597 
symptoms  of,  596 
treatment  of,  .">!)7 
biliary,  5!)S 
( Ilimatic  cures,  256 
Coagulen,  715 
Coagulose,  516 

Cocain  hydrochlorid  as  a  gastric  seda- 
tive, 269 
Coccygodynia,  850 
treatment  of,  850 

cauterization,  850 
massage,  850 
sedative,  850 
Cocoa,  acorn,  194 

nutritive  value  of,  169 
protein-milk-salt,  193 
Cod-liver  oil,  194 
Coffee,  effect  of,  on  digestion,  169 
Coils,  Leiter's,  251 
Cold  entire  pack,  247 
Colectomy  in  various  diseases,  697 
Colica  flatulent  a,  783 
Coliques  salivaires,  327 
Colitis,   635.     See  also   Enteritis    and 
Intestinal  catarrh, 
acute,  635 

chronica  ulcerosa,  730 
dry  treatment  of,  237 
membranous,  high-frequency  cur- 
rent in,  219 
mucous,  652 

enteroptosis  and,  653 
spastic  constipation  and,  670 
vagotonia  and,  653 
ulcerative,  730 

bacteria  in  etiology  of,  730 
complications  of,  731 
creosote  and  cod-liver  oil  in, 

732 
diagnosis  of,  731 
lavage  and  irrigation  in,  733 
opium  and  pantopon  in,  732 
pathology  of,  730 
perisigmoiditis  and,  731 
symptoms  of,  731 
treatment  of,  732 
"dry,"  734 
local,  733 
Matthews',  733 
vaccine,  735 
Colon,  carcinoma  of,  764.     See  Carci- 
noma of  colon, 
deviations   from   normal   position 

of,  146 
dilatation  of,  790 


870 


INDEX 


Colon,  dilatation  of,  in  boys,  791 
etiology  of,  791 
idiopathic,  790 
prognosis  of,  792 
roentgenography  in  diagnosis 

of,  791 
symptoms  of,  792 
treatment  of,  793 
inflammation  of,  635.     See  Colitis, 
irrigation  of,  221 
normal  motility  of,  145 
position  of,  145 
roentgenography  of,  145 
transverse,  displacement  of,  146 
tube,  220 
Colonic  irrigation,  posture  in,  221 
technic  of,  221 
stasis,  roentgenography  in,  147 
Coloptosis,  559,  560 

roentgenographic  diagnosis  of,  146 
Compresses,  250 

Condurango  bark  as  a  stomachic,  267 
Connective-tissue   adhesions,   massage 
in,  208 
digestion,  674 

in  feces,  significance  of,  119,  674 
Constipating  diet,  172 
Constipation,  acute,  water  enemata  in, 
227 
agar  in  treatment  of,  184,  662 
atonic,  659 

etiology  of,  659 

magnesium    sulphate    subcu- 

taneously  in,  666 
mineral  waters  in,  667 
roentgenography  in,  661 
symptoms  of,  660 
test-diet  stool  findings  in,  133, 

661 
treatment  of,  661 

dietetic,  182,  184,  185 
by  enemata,  223,  668 
electrical,  219 
general,  665 
hormone,  667 
lavage,  666 
liquid  petrolatum,  664 
massage,  208,  664 
medicinal,  666 
surgical,  668 
with  agar,  662 
with  grapes,  664 
chronic,  659 

atonic,  agar  in,  185,  662 
diet  in,  185 
oil  enemata  in,  223 
paraffin  enemata  in,  225 
bile  enemata  in,  226 
carbon  dioxid  enemata  in,  226 
cathartics  by  enema  in,  227 
electricity  in,  230 
enemata  in,  222 
etiology  of,  659 
feces  in,  660 
massage  in,  214 


Constipation,  chronic,  oil  enemata  in, 
223 
paraffin  enemata  in,  225 
rectal  friction  in,  229 
massage  in,  229 
tampons  in,  230 
Swedish  manipulation  in,  228 
symptoms  of,  660 
test-diet  stool  of,  661 
transverse  colon  and,  146 
cleansing  enemata  in,  220 
diet  in,  182-186 
early,  from  megacolon,  791 
fragmentary,  672 

treatment  of,  672 
fruit  in  diet  of,  184 
glycerin  enemata  in,  222 
hemicellulose  in,  184 
intestinal  irrigation  in,  666 
lavage,  duodenal,  in,  107 
liquid  petrolatum  in,  226 
massage  in,  214 
mineral  waters  in,  254 
movement  of  bismuth  mass  in,  146 
nervous  dyspepsia  and,  419 
perisigmoiditis  and,  785 
rectal,  retention  of  bismuth  in,  146 
spastic,  668 

action  of  opium  in,  672 
cause  of,  668 
colitis  and,  670 
diagnosis  of,  670 
innervation  of  intestine  in,  668 
irritating    foods   contra-indi- 
cated in,  186 
purgatives      contra-indicated 

in,  672 
roentgenography  in,  669 
sex  incidence  of,  669 
symptoms  of,  669 
test-diet  stool  findings  in,  134, 

670 
treatment  of,  670 
antispastic,  672 
dietetic,  670 

by  dilatation  of  anus,  671 
electric,  219,  671 
fruit  sugars  in,  185 
by  oil  enemata,  223,  671 
with    hot    and    cold    air 
douche,  671 
vegetative  nervous  system  and, 
668 
Constitutional  diseases,  effect  of,  upon 

mouth,  301,  302 
Contrary  innervation,  law  of,  65 
Convulsions  from  overeating,  lavage  in, 

198 
Corpus  luteum  in  pernicious  vomiting 

of  pregnancy,  405 
Corrosions  of  esophagus,  357 
Corsets,  abdominal,  580 
Crawcour's  esophageal  sound,  367 
Cream  protein  mixture,  Pfund's,  194 
Crede's  bougie,  838 


i.\i>i:\ 


871 


CnkltVs  method  of  gastric  massage,  210 

Crises,  gastro-intestinal,  089 

Croton  oil  in  atonic  constipation,  667 

(  'nstals  in  stomach  contents,  94 

Curve  of  gastric  digestion,  79 

Cynorexia,  415 

Cystitis  from  trema lodes,  818 

(  "ysts  of  bile  ducts,  tilt) 

dermoid,  of  mouth,  337 

of  esophagus,  362 

from  glands  of  mouth,  338 

maxillary,  :>4."> 

of  pancreas,  032 

at  root  of  tongue,  339 

of  stomach,  555 
Cytase,  59,  61 


Diarrhea,  nervous,  diagnosis  of,  681 
etiology  of,  0S0 
psychogenic,  0S0 
reflex,  680 

symptoms  of,  081 

test-diet  stool  findingsin,   134, 

osl 
treatment  of,  0S1 
dietetic,  0S2 
mental,  681 
with  epinephrin,  082 

remedial  value  of,  in  enteritis,  638 

spastic,  670 

strychnin  in,  407 

tannin  preparations  in,  277 

tubular,  052 


Cytodiagnosis  of  gastric  carcinoma,  87   Diastase  in  feces,  Wohlgemuth's  test 

tor,  YJi  i 
Diastatic  ferments,  medicinal  use  of, 

D  2u3 

Diet  in  acute  appendicitis,  777 

dysentery,  722 
enterocolitis,  039 
gastritis,  452 
infectious  gastritis,  454 
intestinal  catarrh,  039 
in  anal  fissure,  800 
antidiabetic,  in  pancreatic  fistula, 

030 
antifermentative,  181 
antiputrefactive,  174 
antiseptic,  174,  689 
astringent,  177 
in   atonic  constipation,    183,    184, 

001 
in  cardiospasm,  393 
cellulose  in,  179,  183 
in  cholangitis  and  cholecystitis,  013 
in  cholelithiasis,  620 
in  chronic  appendicitis,  non-opera- 
tive, 779 
dysentery,  727 
gastritis,  460 
gastrorrhea,  444 
intestinal   catarrh   with   con- 
stipation, 050 
with  diarrhea,  047 
pancreatitis,  027 
constipating,  172 
in  constipation,  182-180 

'   spastic,  070 
in  diarrhea,  172,  039 
gastrogenic,  076 
nervous,  082 
in  dilatation  of  colon,  793 
in  duodenal  ulcer,  711 
in  enteritis  membranacea,  054 
in  flatulence,  701 
in  gastric  atony,  475 
carcinoma,  547,  551 
diseases,  151 
ulcer,  499,  500 
in  gastritis,  acute,  452 

infectious,  454 
in  gastroenteroptosis,  509,  571 


Defense    musculaire    in  appendicitis, 
709,  775 
in  duodenal  ulcer,  709 
Deglutition  sounds,  350 
Delineator  string  in  diagnosis  of  cardio- 
spasm, 390 
of  pylorospasm,  399 
Dentifrices  recommended,  294,  295 
Dermoid  cysts  in  esophagus,  302 

in  mouth,  337 
Dextrose,  50 

Diabetes,    bronze,    with    hypertrophic 
cirrhosis  of  liver,  597 
nielli tus,  lavage  in,  198 
pyorrhea  and,  303 
Diagnosis  and  pathologic  stools,  119 
Diaphragm,  displacement  of,  500 
Diarrhea,  acute,  035 
chronic,  073 

agar-tannin  in,  278 
condition  of  stomach  and,  074 
diet  in,  172 

ferruginous  waters  in,  250 
from  decomposable  fluids,  173 
from  transudation  of  serum,  173 
gambir  in,  278 
gastrogenic,  173,  180,  073 

bacterial  processes  in,  075 
etiology  of,  074 
examination  of  stomach  con- 
tents in,  070 
fecal  findings  in,  073 
lavage  in,  077 
symptoms  of,  075 
treatment  of,  070 
dietetic,  070 
medicinal,  077 
with  acids  or  alkalis,  070 
with  reference  to  stomach, 
070 
in  intestinal  tuberculosis,  738 
hematoxylon  in,  278 
milk  somatose  in,  277 
nervous,  080 


872 


INDEX 


Diet  in  hemorrhoids,  823 
in  hyperchlorhydria,  432 
in  hypersecretion,  444 
in  ileus,  749 
instruction  of  patient  regarding, 

169 
in  intestinal  catarrh,  639,  647,  650 
diseases,  172 
fermentative  dj'spepsia,    181, 

679 
hemorrhage,-  172 
putrefaction,  174,  178 
stricture,  759 
toxemia,  689 
tuberculosis,  739 
ulcer,  172,  711,  714,  732 
laxative,  182 
milk  as  an  article  of,  174 
in    motor    insufficiency    of    first 
degree,  475 
of  second  degree,  481 
in  mucous  colitis,  654 
in  nervous  dyspepsia,  421 
in  pancreatic  affections,  627,  629 
and  patient's  preference,  152 
in  pruritus  ani,  853 
in  putrefactive  intestinal  diseases, 

174 
in  rectal  paralysis,  849 

prolapse,  846 
Schmidt,  112,  179,  180 
sustaining,  570 
in  thread  worm,  805 
in  typhoid  fever,  713 
in  ulcerative  colitis,  732 
vitamin  in  the,  15,7 
Dietary  instructions,  169 

regulations  and  lists,  152 
Dietetic  treatment  and  stomach  tube, 

151 
Digestibility  of  foods,  156 
Digestion,  activators  of,  53,  157 
carbohydrate,  in  stomach,  85 
effect  of  alcohol  on,  168 
gastric,  52 
gelatin  test  of,  84 
intestinal,  56,  61 
kinases  in,  53 

Pawlow's  experiments  in,  52,  54,  56 
physiology  of,  49 
salivary,  49 

shown  by  food  beads,  129 
Dilatation  of  anus  in  rectal  stricture, 
839 
in  spastic  constipation,  672 
of  biliary  organs,  615 
of  colon,  idiopathic,  790 

roentgenography  in,  148 
of  esophageal  stricture,  368 
of  esophagus,  380 
of  rectal  stricture,  839,  841 
of  stomach,  95,  478 
acute,  486 

shown    by    roentgenograph', 
140 


Dilatation  of  stomach,    stomach   con- 
tents in,  95 
treatment  of,  486 
by  lavage,  487 
by  massage,  208 
Dilators,  esophageal,  370 

rectal,  839,  840 
Dimethylamidoazobenzol  test  for  free 

hydrochloric  acid,  75 
Dinner,  test,  68 
Diphtheria  in  esophagus,  356 
Distoma  hematobium,  816,  817 
hepaticum,  817 
lanceolatum,  817 
Diverticula  of  esophagus,  365,  374 

of  sigmoid,  786,  787,  788 
Diverticular  sounds,  376 
Diverticulitis,  roentgenograph}'  of,  148 
sigmoidal,  786 

etiology  of,  788 
pathology  of,  788 
Dochmius  duodenalis,  806 
Dorsal  pain  of  gastric  ulcer,  491 
Double  capsule  method  of  administer- 
ing hydrochloric  acid,  260 
Douches.  251 

intestinal,  228 
Draining  gall  bladder  and  bile  ducts, 

104 
Drinking  cures,  254,  256 
Dropsv,  Karell  cure  for,  163 
Drum-belly,  403 
Dry  treatment  of  colitis,  237 

of  intestinal  catarrh,  237 
of  ulcerative  enteritis,  734 
Dumb-bell  pessar y  for  hemorrhoids,  826 
Duodenal  alimentation,  Einhorn's  tube 
for,  500 
in  gastric  ulcer,  500,  502,  508 
Morgan's  modification  of  Ein- 
horn's, 502 
technic  of,  501 
bag,  Hemmeter's,  98 
bucket,  Einhorn's,  91 
cap,  143 
carcinoma,  762 
contents  after  test  meal,  101 
characteristics  of,  101 
examination  of,  98 
in  duodenal  ulcer,  110 
in  duodenitis,  110 
inliver  and  gall  bladder  lesions , 

101 
pancreatic  juice  in,  109 
in  pancreatitis,  109 
in  pernicious  anemia,  110 
results  of   direct  examination 
_  of,  109 
significance  of  bile  in,  109 
of  typhoid  carriers,  110 
in  typhoid  fever,  110 
urobilin  and  urobilinogen   in, 
101 
enzymes,  determination  of,  103 
examination  for,  102 


/.\  />/<:. v 


873 


Duodenal  enzymes  in   pathologic  con- 
ditions," L03 
feeding,    500.    See    Duodenalah- 

mentation. 
fluid,  bacteria  in,  107 
lavage,  105 

indications  for,  107 
for  intestinal  stasis,  107 
irrigating  fluid  employed  in, 

106 
Jutte's  apparatus  for,  104,  105 
technic  of,  106 
medication,  direct,  104 
tube,  an  aid  to  the  passage  of,  100 
determination   of,   in   duode- 
num, 100 
Einhorn's,  98,  500 
Gross's,  100 
Jutte's,  100 
Kuhn's,  98 
Palefski's,  100 
ulcer,  705.     See  Ulcer,  duodenal. 
Duodenitis,  duodenal  contents  in,  110 
Duodenum,  bacteriology  of,  107 
displacement  of,  559 
Hemmeter's  apparatus  for  enter- 
ing, 98 
peptic  ulcer  of,  705 
See  also  Duodenal. 
Dyschezia,  146,  666 
Dysenteric  pains,  epinephrin  in,   725, 

726,  727 
Dysentery,  acute,  719 

catechu  bark  in,  725 
complications  of,  721 
epinephrin  irrigations  in,  726 
iodoform  in,  726 
magnesium  sulphate  in,  725 
pathology  of,  720 
prognosis  of,  721 
prophylaxis  of,  721 
silvol  enemata  in,  726 
symptoms  of,  720 
tannic  acid  enteroclysis  in,  726 
treatment  of,  722 
dietetic,  722     ■ 
medicinal,  722 
amebic,  arsphenamine  in,  725 
benzyl  benzoate  in,  724 
bismuth  subnitrate  in,  726 
emetin  in,  723 

emetin-bismuth  iodid  in,  724 
epinephrin  in,  725 
from  trematodes,  818 
ipecac  in,  722 
simaruba  bark  in,  725 
uzara  in,  725 
bacillary,  727 
chronic,  719,  727 

appendicostomy  in,  729 

castor  oil  in,  728 

diet  in,  727 

emetin  or  ipecac  in,  728 

iodoform  enemata  in,  728 

lactic  acid  cultures  in,  727 


Dysentery,  chronic,  olive  oil  in,  728 
pathology  of,  720 

site  of  lesions  in,  728 

treatment  of,  727 
medicinal,  728 
surgical,  728 

ulcers  in,  720 
complications  of,  721 
differentiation  ot  acute  and  chron- 
ic 720 
endemic,  719 
epidemic,  719 

antidysenteric  serum  in,  727 
from  parasites,  719 
from  trematodes,  818 
microbic  causes  of,  719 
pathology  of,  720 
test-diet  stool  findings  in,  133 
Dyspepsia,  intestinal  fermentative,  181, 
677 
etiology  of,  678 
oxygen  insufflation  in,  679 
test-diet  stools  in,  134,678 
treatment  of,  679 
nervous,  418 

causes  of,  418,  419 
definition  of,  418 
eye  strain  and,  418 
HC1  secretion  in,  420 
lactovegetable  diet  list  for,  422 
massage  in,  208,  423 
obstetric  lacerations  and,  419 
prognosis  of,  420 
prophylaxis  of,  420 
sea-water  therapy  in,  423 

apparatus  for  appli- 
cation of,  424 
symptoms  of,  419 
treatment  of,  421 
dietetic,  421 
etiologic,  421 
medicinal,  425 
physical,  423 
sea-water,  423 
umbilical,  428 
Dyspeptine,  262 


E 


Echinococci  in  bile  ducts,  616 
in  liver,  602,  604 

diagnosis  of,  603 

etiology  of,  602 

symptoms  of,  603 

treatment  of,  604 
Echinococcus  multilocularis  in  liver,604 
Eclampsia,  lavage  in,  198 
Eczema,  labial,  317 

oral  carcinoma  and,  342 
Effervescence  test  of  gastric  function,SS 
Effleurage,  213 

Egg  protein  preparations,  192 
Eggs  in  diet,  161 

food  value  of,  162 


874 


INDEX 


Eggs,  preparation  of,  161 
Einhorn's  agar  tubes,  102 

apparatus  for  stomach  douche,  205 
bead  test  of  gastro-intestinal  motil- 
ity, 129 
duodenal  alimentation,  500 
bucket,  91 
tube,  98,  500 
intragastric  electrode,  217 
pyloric  dilator,  400,  485 
stomach  bucket,  70 
test  meal  before  examining  duo- 
denal contents,  101 
Elbrecht's  heating  apparatus  for  proc- 
toclysis, 240,  241,  242,  243 
Electricity  in  acute  intestinal  catarrh, 
651 
in  digestive  disorders,  219 
in  gastralgia,  215,  219 
in  gastric  disorders,  214,  215,  219 
in  gastroenteroptosis,  574 
in  gastroptosis,  215 
in  intestinal  diseases,  230 
in  mucous  colitis,  656 
in  vomiting,  hysterical,  215 
of  pregnancy,  215 
Electrization  in  chronic  constipation, 
230 
extraventricular,  219 

technic  of,  219 
intraventricular,  216 

apparatus  for,  216 
of  stomach,  indications  for,  215 
Electro-colloids  for  intravenous  injec- 
tion, 581 
Electrode  and  stomach  tube  combined, 
Stockton's,  218 
Boas',  216,  231 
Einhorn's,  217 
hemorrhoidal,  Williams',  832 
intragastric,  216,  217 
rectal,  230,  231,  232 
Wegele's,  217 
Zweig's,  231 
Electrolysis  in  treatment  of  internal 

hemorrhoids,  831 
Electrotherapy  in  cardiospasm,  398 
Embolic  ulcers  of  intestine,  741 
Embryonic  membrane,  561 
Emetin  in  amebic  dysentery,  723 
Emetin-bismuth  ioclld  in  amebic  dysen- 
tery, 724 
Emollients  in  gastric  diseases,  272 
Empyema  of  gall  bladder,  616 
Endothelioma  of  mouth,  340 
Enemata  in  atonic  constipation,  220, 
666 
bile,  226 
carbon  dioxid,  226 

apparatus   for  administering, 
227 
of  cathartics,  227 
cleansing,  apparatus  for  adminis- 
tering, 221 
technic  of,  220 


Enemata,  glycerin,  222 

in  intestinal  stenosis,  227 
nutrient,  243 
oil,  223 

apparatus   for   administering , 
224,  225 
paraffin,  225 
Enemator,  Roberts'  oil,  225 

Zweig's  oil,  223 
Enteralgia,  causes  of,  783 
nervosa,  783 
treatment  of,  784 
Enteritis,  chronic,  644.     See  also  Intes- 
tinal catarrh,  chronic, 
membranacea,  652 

appendicitis  and,  587 
etiology  of,  652 
pathology  of,  652 
surgery  in,  657 
symptoms  of,  653 
test-diet  stool  findings  in,  133 
treatment  of,  653 
anodyne,  658 
antispastic,  656,  658 
dietetic,  654 
electric,  656 
hydro  therapeutic,  656 
irrigation,  655 
laxative,  656,  658 
massage,  656 
sea-water,  657 
vaccine,  656 
with  anemia,  654 
mucomembranous,  652 
ulcerative,  730 

bismuth  subgallate  in,  734 
complications  of,  731 
course  of,  731 
creosote  and  cod-liver  oil  in, 

732 
diagnosis  of,  731 
diet  in,  732 

"dry  treatment"  of,  734 
etiology  of,  730 
exudates  from,  73 1 .     See  Peri- 
sigmoiditis, 
irrigations  in,  733 
lavage  in,  733 
opium  in,  732 

pathologic  anatomy  of,  730 
prognosis  of,  731 
treatment  of,  732 
Matthews',  733 
surgical,  735 
vaccine,  735 
Enterocolitis,  acute,  635.     See  Intesti- 
nal catarrh, 
chronic,  644 
Enterokinase,  59 
Enteroptosis,  557 

mucous  colitis  and,  653 
nervous  dyspepsia  and,  419 
Enterospasm,  feces  in,  781 
symptoms  of,  781 
treatment  of,  781 


INDEX 


S7fi 


Enzymes,  53 

catalj  tic  acl  ion  of,  53 
duodenal,  estimation  of,  102 
examination  for,  83 
in  stomach,  tests  for,  83 
Eosinophilic  in  hookworm  disease,  811 
in  round  worm,  800 
in  t  richinosis,  819 
Epigastric  hernia  and  nervous  dyspep- 
sia, 419 
Epinephrin  (adrenalin)  iii  anal  fissure, 
861 
in  diagnosis  of  pancreatic    insnili- 

ciency,  626 
in  dysenteric  pains,  725,  726,  727 
in  esophageal  corrosions,  358 
in  gastric  hemorrhage,  271,  517 
in  hemorrhoids,  823 
irrigations  in  dysentery,  726 
in  nervous  diarrhea,  682 
in  pylorospasm,  400 
in  vomiting  of  pregnancy,  404 
vs.  pilocarpin,  390 
Epulis,  346 
Erepsin,  59 

Erosions  of  mouth,  303 
of  stomach,  97,  521 

acute  or  hemorrhagic,  521 

chronic,  521 

diagnosis  of,  522 

effect  of,  on  stomach  contents, 

97 
etiology  of,  521 
pathology  of,  522 
prognosis  of,  523 
symptoms  of,  522 
treatment  of,  523 

hydrotherapeutic,  523 
local,  523 

with  bismuth,  524 
with    silver    nitrate, 

523 
with  suprarenal 
gland,  524 
Eructation,  nervous,  401 
Erysiptelas,  scleroma  and,  315 
Erysipelatous  stomatitis,  307 

treatment  of,  307 
Erythema  exudativum  multiforme  of 

oral  mucosa,  318 
Erythrodextrin,  50 
Escalin  in  gastric  hemorrhage,  518 
Esmarch's  rectal  truss,  847 
Esophageal  anesthesia,  385 
atony,  386 
bougie,  350 

and    cannula     (Leyden    and 
Renvers),  371 
carcinoma,    362.     See   Carcinoma 

of  esophagus, 
dilatation,  congenital,  382 
diagnosis  of,  381 
etiology  of,  380 
prognosis  of,  381 
roentgenography  in,  381 


Esophageal   dilatation,   symptoms   of, 
380 

I  real  liieul   of,  381 

dilator,  Schreiber's,  370 

Senator's,  370 

Sippy's,  369,  370 
diphl  heria,  356 
diverticula,  365,  374 
pulsion,  374 

diagnosis  of,  -J7.") 

roentgenographs,  138 
prognosis  of,  .'i7o 
symptoms  of,  375 
treat  uient  of,  376 
sound  treatment  of,  365 
traction,  37  1 
hemorrhage,  383 
hyperesthesia,  3S4 
malacia,  383 
neuroses,  384 
paralysis,  385 
perforation,  383 
rupture,  383 
sound  (Crawcour's),  367 
sounds,  365,  376 

introduction  of,  365,  367 
spasm,  378 

roentgenologic  appearance  of, 

137 
symptoms  of,  378 
treatment  of,  379 
stricture,  364 

alimentation  in,  372 
congenital,  383 
dilatation  of,  368 
from  dilatation.     See  Esopha- 
geal dilatation, 
from  diverticula,  374 
from  external  compression,378 
from  foreign  bodies,  377 
from  neoplasms,  362 
from  spasm  of  esophagus,  378 
from  thrush,  378 
treatment  of,  general,  373 
sound,  364 
surgical,  372 
syringe,  Rosenheim's,  354 
tuberculosis,  359 

variola,  357.     See  also  Esophagus. 
Esophagitis,  acute,  353 

treatment  of,  353 
chronic,  353 

treatment  of,  354 
exfoliative,  353 

treatment  of,  355 
fibrinous,  355 

treatment  of,  355 
phlegmonous,  356 

treatment  of,  356 
Esophagoscope,  351,  352 
introduction  of,  351 
in  locating  diverticula,  375 
Esophagus,  actinomycosis  of,  361 
anatomy  of,  349 
atony  of,  386 


876 


INDEX 


Esophagus,  burns  of,  357 

carcinoma  of,  362.    See  Carcinoma 

of  esophagus, 
cicatricial  stricture  of,  364 
corrosions  of,  357 
cysts  of,  362 
dermoids  of,  362 
dilatation  of,  380 
diseases  of,  349 
fibroma  of,  362 
foreign  bodies  in,  377 
gangrene  of,  358 
herpes  zoster  in,  357 
hypertrophy  of,  362 
infectious  diseases  of,  356 
inflammation  of,  353 
instrumental  examination  of,  350 
lipoma  of,  362 
myoma  of,  362 
neuroses  of,  384 
papilloma  of,  362 
parasites  in,  361 
pemphigus  in,  357 
Roentgen-ray  examination  of,  136 
sarcoma  of,  364 
stricture  of,  361,  364,  378,  383 

.    cicatricial,  treatment  of,  364 
syphilis  of,  359 
thrush  of,  361 
tuberculosis  of,  359 
ulcers  of,  358 
peptic,  360 
See  also  Esophageal. 
Etat  mamelonne,  461 
Eucasin,  192 
Eumydrin  in  gastric  diseases,  271,  446 

in  hypersecretion,  271 
Examination  of  duodenal  contents,  98 
for  enzymes,  83,  102 
of  feces,  111.     See  Feces, 
macroscopic,  115 
microscopic,  115 
of  intestine,  143 
of  stomach  contents,  66 
chemical,  74 
macroscopic,  68 
microscopic,  92 
roentgenologic,  135 
See  also  Stomach  contents. 
Exanthems,  medicinal,  301 
Exercise  after  eating,  170 
Experimental  ulcer,  706 
Expression  method  of  obtaining  stom- 
ach contents,  68 
Eye-strain  as  a  cause  of  gastric  neuro- 
ses, 418 
headache  and,  418 


Facial  nerve,  paralysis  of,  320 
Faradization  of  stomach,  215,  218,  219 
Fat  absoprtion,  60 

in  diet  of  gastric  patients,  152,  162 


Fat  digestion  in  chronic  pancreatitis, 
625 
in  feces,  120,  127 
in  food  cures,  572 
importance  of,  in  the  dietary,  572 
limitation  of,  in  chronic  pancrea- 
titis, 627 
Fat-digestion  tests,  127 
Fat-splitting  ferment,  lipase,  56 
Fats  permissible  in  stomach  diseases, 
162 
preparation  for  digestion  of,  56 
retention  of,  in  stomach,  51 
Fatty  liver,  604 

Fauces,  effects  of  rubeola  on,  302 
Febrilis  icterus,  587 

etiology  of,  588 
serum  treatment  of,  588 
Fecal  analysis,  apparatus  for  making, 

114 
Feces,  carbohydrates  in,  121 
composition  of,  65 
connective  tissue  in,  119 
demonstration  of  ferments  in,  125 
diastase  in,  test  for,  127 
in  enterospasm,  781 
examination  of,  111 
for  bacteria,  118 
for  blood,  123,  124 
chemical,  116 

for  bilirubin,  122 
for  dissolved  protein,  117 
reaction  test,  116 
Schmidt's  incubator  test, 
116 
sublimate  test,  116 
Strasburger's     fermenta- 
tion tubes,  117 
in  duodenal  ulcer,  133,  709 
in  gastrogenic  diarrhea,  673, 

674 
in  intestinal  fermentative  dys- 
pepsia, 677 
for  protein,  117 
for  pus,  122 
test  diet  in,  112 
fat  in,  120,  127 

fermentation  of  putrefaction  of ,  172 
in  intestinal  catarrh,  637 
mucus  in,  121 
muscle  remnants  in,  120 
normal  after  test  diet,  119 
nuclei  in,  126 
potato  remnants  in,  121 
protein  in,  121 
starch  in,  121 
steapsin  in,  125 
trypsin  in,  125 
See  also  Test-diet  stool  findings. 
Feeding  in  diseases  of  mouth,  298 
Fermentation  tubes,  Strasburger's,  116 
Fermentative  dyspepsia,  181 
Ferments  in  feces,_  demonstration  of,  125 
Ferruginous  waters,  254 
Fersan,  188 


INDEX 


s77 


Fetor  i  x  art  from  bromide  and  iodide, 
301 
in  catarrhal  stomatitis,  305 
from   esophageal   dilatations, 

UNO 

in  esophageal  diverticula,  375 
in  gangrenous  stomatitis,  306 
from  mercury,  300 
in  uoma,  307 

to  remove,  296 
in  pemphigus  of  oral  mucosa, 

318 
treatment  of,  296 
l'iliroly.-in  in  pyloric  stenosis,  484 
Fibroma  of  esophagus,  362 
of  ina\illa\  3  15 
of  mouth,  335 
of  stomach,  555 
Fibromyoma  of  stomach,  555 
Filtering  gastric  contents,  reason  for,  78 
Fissure  of  anus,  858 
Fistula  in  ano,  857 

of  lower  lip,  333 
Flatulence,  698 

aerophagy  and,  701 
endogenous  gas  in,  699 
exogenous  gas  in,  699 
from  cardiac  disease,  704 
from  food  decomposition,  700 
from  impeded  expulsion  of  gases, 

700 
from  intestinal  stricture,  704 
from  microorganisms,  699 
origin  of,  698 
nervous,  700 
pseudo,  700 

relieved  by  attention  and  sleep. 701 
treatment  of,  700 
dietetic,  701 
by  intubation,  703 
by  massage,  702 
medicinal,  702  • 
Fleiner's  oil  enemata  in  spastic  consti- 
pation, 223,  671 
Flies  in  intestine,  820 
Floating  kidney,  566 

chronic  appendicitis  and,  768 
Flour,  aleuronat,  191 
dextrinated,  193 
preparations,  193 
Flours  in  diet,  193 
Fluctuating  rib  and  gastroenteroptosis, 

563 
Fluke  worms,  816 
Focal  infection,  290 
Follicular  tonsillitis.  347 
Food,  antiseptic,  174 
astringent,  177 
caloric  value  of,  151 
chemical  composition  of,  151 
cures,  carbohydrates  in,  572 
fats  in,  572 
proteins  in,  571 
preparations,  artificial,  177,  187 
cows'  milk  and,  189 


1 1  preparations  containing  fat,  194 

cod-liver  oil,  194 

lipanin,   l'.M 

Merings  "  Kraft  " 

chocolate,  194 
nutrole,  194 
oil  of  sesame,  194 
Russell's  emulsion, 

194 
sevetol,  I'M 
from  animal  protein,  187 
from  carbohydrates,  192 
from  egg  protein,  192 
from  milk  protein,  194 
from  vegetable  protein,  191 
mixed,  193 

acorn  cocoa,  194 
hygiama,  193 
odda,  193 
protein-milk-salt     cocoa, 

193 
racahout,  194 
products,  average  composition  of, 

153,  155 
remnants,  pathologic,  119 
requirements  in  health,  156 
stimulating,  194 
values,  151-169 

Atwaters  table  of,  153-155 
Foods,  digestibility  of,  156 
heat  value  of,  151 
proprietary,  191 
Foot-and-mouth  disease  in  man,  302 
Foreign  bodies  in  esophagus,  377 
Fractional   analysis   of   stomach   con- 
tents, 78 
Fragmentary  constipation,  672 
Friedlieb's  stomach  tube,  202,  203 
Friedrich's  test  for  HO  in  stomach,  89 
Fruit  in  diet  of  constipation,  184,  185 

of  gastric  patients,  167 
Funnel  pessary  for  hemorrhoids,  826 


G 


Galactogex,  192 
Gall  bladder,  drainage  of,  104 
empyema  of,  616 
■  hydrops  of,  616 
neoplasms  of,  614 
roentgenography  of,  149 
Gall-bladder  disease,  duodenal  bile  in, 
109 
diseases,  607 
Gallstone  colic,  treatment  of,  619 

ileus,  chloroform-water  irrigations 
in,  227 
Gallstones,  616.    See  also  Cholelithiasis, 
as  a  cause  of  nervous  dvspepsia, 

419 
diagnosis  of,  618 

roentgenography  in,  150,  618 
non-surgical  drainage  for,  104,  621 
origin  of,  617 


878 


INDEX 


Gallstones,  surgical  removal  of,  622 
symptoms  of,  618 
treatment  of,  619 
Galvanofaradization  of  stomach,  218 
Gambir,  278 

Gangrene  of  esophagus,  358 
Gangrenous  stomatitis,  305 
treatment  of,  306 
Gas-producing  organisms  in  duodenal 

fluid,  108 
Gases,  fermentative  and  putrefactive, 
700 
in  flatulence,  endogenous,  699 

exogenous,  699 
from  microorganisms,  699 
in  intestine,  origin  of,  699 
Gasterin,  262 
Gastralgia,  266,  270,  410 
anesthesin  in,  270 
belladonna  in,  271 
bismuth  in,  "66 
causes  of,  410 
chloroform  in,  270 
electricity  in,  215,  219 
Franke's  operation  in,  412 
nervous,  massage  and  medicated 

lavage  in,  210 
orthoform-new  in,  270 
rhizotomy  in,  412 
strychnin  in,  236 
treatment  of,  410 
Gastralgokenosis,  414 
Gastric  analysis,  indirect  methods  of, 
88.     See  Stomach  contents, 
anodynes,  270 

carcinoma,    97,    537.     See   Carci- 
noma of  stomach, 
catarrh,  diet  in,  151 

mineral  waters  in,  255,  256 
crises  in  intestinal  toxemia,  689 

vagus  and  sympathetic,  412 
digestion,  52 
curve  of,  79 
Giinzburg's  test  of,  89 
Sahli's  desmoid  test  of,  90 
dilatation    with    pyloric    stenosis, 
lavage  in,  197 
massage  in,  208 
postoperative  lavage 
in,  197 
diseases,  acidol  in,  260 
alcohol  in,  168,  267 
alkalis  in,  263 
antiseptics  in,  272 

hydrogen  peroxid,  272 
iodin,  272 

magnesium  peroxid,  273 
phenol,  272 
resorcinol,  272 
salicylates,  272 
bismuth  in,  265,  266 
bitters  in,  266 
diet  in,  151 

drugs    used    incidentally   in, 
271 


Gastric  diseases,  drugs  used  incidentally 
in,    atropin,    pilo- 
carpin  and  nicotin, 
271 
epinephrin,  271 
eumydrin,  271 
gasterin  in,  262 
gastric  anodynes  in,  270 
sedatives  in,  268 

amyl  nitrite,  268 
bromids,  269 
cannabis,  269 
chloral  hydrate,  269 
cocain  hydrochlorid, 

269 
dilute     hydrocyanic 

acid,  269 
nitroglycerin,  269 
hydrochloric  acid  in,  258 
olive  oil  in,  273 
orexin  in,  267 
pancreatin  in,  262 
pepsin  in,  258 
silver  nitrate  in,  267 
strychnin  in,  266 
tobacco  in,  169 
water  in  diet  of,  168 
glands,  tubular,  54 
hemorrhage,     511.     See     Hemor- 
rhage, gastric, 
hyperacidity,  94.     See  Hyperacid- 
ity and  Hyperchlorhydria. 
hyperesthesia,  413 

silver  nitrate  in,  413 
Stockton's  sedatives  in,  414 
irritation,  mud  baths  in,  257 
juice,  acidity  of,  54 

after  ingestion  of  bread,  53 

of  milk,  53 
color  of,  73 
consistency  of,  74 
determination  of,  73 
normal,  54 
odor  of,  74 
lavage.     See  Lavage  of  stomach, 
motility,    chlorophyl  test  of,    91. 
See  Motor  function  of  stomach 
and  Motor  insufficiency, 
mucus,  lavage  for  removal  of,  197, 

205 
neuroses,  94 

eye-strain  and,  418 
mud  baths  in,  257 
peristalsis  and  duodenal  ulcer,  144 
retention,  massage  in,  208 
secretion,  changes  in,  due  to  path- 
ologic conditions,  94 
in  duodenal  ulcer,  709 
duration  of,  55 
meat  and,  53 
in  nervous  dyspepsia/  94 
psychic  initiation  of,  55 
Sahli's  desmoid  test  for,  90 
stimulants  of,  267 
vagus  nerve  and,  54 


INDEX 


879 


( lastric  sedatives,  I'C.S 

subacidity,  test-diel  stool  findings 
in,  131 

tetany,  4Sf> 

lavage  in,   IDS 
tonus,  roentgenography  of,  140 
ulcer,  !•?.     <SVc  I 'leer,  gastric. 
( last  ril  is,  acid,  402 
acute,  95,  449 

infectious,  453 

etiology  of,  453 
pathology  of,  453 
symptoms  of,  454 
treatment  of,  454 
dietetic,  454 
by  lavage,  454 
medicinal,  454 
simple,  449 

course  of,  450 
etiology  of,  449 
pathology  of,  449 
prophylaxis  of,  450 
symptoms  of,  450 
treatment  of,  450 
dietetic,  452 
by  lavage,  198,  450 
medicinal,  452 
sodium  chlorid  waters  in,  253 
stomach  contents  in,  95 
anacid,  463.     See  Achylia  gastrica. 
chronic,  95,  460 

diagnosis  of,  462 
etiology  of,  460 
HC1  secretion  in,  95 
massage  in,  472 
pathology  of,  461 
prognosis  of,  463 
stomach  contents  in,  95 
symptoms  of,  461 
treatment  of,  dietary,  466 
by  lavage,  471 
medicinal,  469 
physical,  472 
with  mineral  waters,  253, 
472 
phlegmonous,  457 
etiology  of,  457 
pathology  of,  458 
symptoms  and  course  of,  458 
treatment  of,  459 
polyposa,  461 
silver  nitrate  in,  268 
subacid,  463 
toxic,  455 

etiology  of,  455 
pathology  of,  455 
prognosis  of,  456 
symptoms  of,  456 
treatment  of,  456 
with  mucus,  lavage  in,  197,  471 
Gastrochylorrhea,  94,  440 
Gastroenteritis,  acute,  635 

from  acute  gastritis,  453 
infantile,   sea-water  in  treatment 
of,  642 


( lasl  roenteroptosis,  557 
Aa ii ni's  sign  of,  565 
bandages  tor  relief  of,  574 
cuiist ipation  and,  562 
corsets  in,  579 

diagnosis  of,  56  1 

el  iology  of,  557 

Hurt uai ing  rib  and,  563 
Ion i is  of,  557 
hyperalimentation  in,  569 

lifting  sign  of,  565 
massage  and  exercise  in,  574 
neurasthenia  and,  562 
point  of  tenderness  in,  564 
pregnancy  and,  557,  581 
prognosis  of,  569 
prophylaxis  of,  569 
symptoms  of,  562 
technic  of  nutrition  in,  571 
treatment  of,  569 
dietetic,  569 
electrotherapeutic,  574 
hydrotherapeutic,  573 
mechanical,  574 
medicinal,  581 
physical,  574 
surgical,  583 
Gastroenterostomy  in  gastric  ulcer,  507 
Gastrogenic   diarrhea,    173,    180,   673. 

See  Diarrhea,  gastrogenic. 
Gastro-intestinal  catarrh,   furruginous 
waters  in,  254 
crises  in  intestinal  toxemia,  690 
motility,  bead  test  for,  129 
neuroses,  treatment  of,  391 
Gastroptosis,  557 

pathology  of,  558 
roentgenography  of,  139 
sea  baths  in,  257 
Gastrorrhea,  94 

acute  intermittent,  440 
chronic,  411.     See  Hypersecretion, 
continuous. 
Gastroscope,  351,  352 
Gastrosuccorrhea,  94,  440.     See  Hyper- 
secretion, continuous. 
Gastroxynsis,  441 
Gauze  test  for  gastric  acidity,  89 
Geographic  tongue,  323 
Gelatin  as  a  culture  medium,  177 

digestibility  and  food  value  of,  161 
in  gastro-intestinal  diseases,  177 
test  of  digestion  and  acidity,  84 
Gingivitis,  333 

in  pregnancy,  303 
Glanders  of  mouth,  314 

treatment  of,  314 
Glass-blowers'  oral  lesions,  304 
Globon,  192 

Glossitis,  acute  diffused,  324 
papular,  325 
chronic  superficial,  325 
manifested  as  coating  or  furring  of 

tongue,  322 
in  tertiary  syphilis,  312 


880 


INDEX 


Glossitis,  treatment  of,  324 

Glossodynia,  321 

Glutanol,  277 

Gluzinski's  test  for  gastric  carcinoma, 

88 
Glycerin  enemata,  222 
Glycyltryptophan  test  for  gastric  carci- 
noma, 87 
Gout,  stomatitis  from,  303 
Grape  cure  of  atonic  constipation,  664 
Green  vegetables  in  gastric  diseases,  167 
Gross's  casein  test  for  trypsin,  125 

duodenal  tube,  100 
Ground-itch  anemia,  806.     See  Hook- 
worm disease, 
treatment  of,  813 
treatment  of,  812 
Gruels  for  gastric  patients,  166 
Grutzner-Gamgee  test  for  steapsin  in 

feces,  126 
Gum,  inflammation  of,  333 
Gum-boil,  331 
Gummata  of  palate,  311 
Giinzberg's  test  of  absorptive  power  of 
stomach,  89 
for  free  HC1  in  stomach  con- 
tents, 76 


H 


Habitus  enteroptoticus,  558 

Hair-tongue,  323 

Half  baths,  248 

Handling  of  intestine,  effect  of,  783  ' 

Hanot's  disease,  596 

Hartenstein's  legumins,  193 

Haudek's  niche,  141 

Headache  from  eye-strain,  418 

from  hypersecretion,  440 
Heat  to  abdomen,  how  applied,  250,251 
unit  for  proctoclysis,  electric,  241, 
242 
gas  or  alcohol,  243 
value  of  foods,  151 
Helminthiasis  and  nervous  dyspepsia, 

419 
Hemangioma  of  mouth,  336 
Hematemesis,   bismuth  subnitrate  in, 
266 
following  stomach  operation,  lav- 
age in,  198 
Hematoxylon,  278 
Hemicellulose  absorption,  61 
in  constipation,  184 
digestion  of,  184 
Hemmeter's  duodenal  apparatus,  98 
Hemocones  in  diagnosis,  611 
Hemoglobin  agar  tubes,  102 
Hemolytic   reactions  in  gastric  carci- 
noma, 543 
Hemorrhage  of  anal  fissure,  861 

differentiation  of  gastric  and  duo- 
denal, 512 
esophageal,  383 


Hemorrhage  from  duodenal  ulcer,  707, 
709 
from  gastric  ulcer,  512 
from  gums  in  hemophilia,  302 

in  purpura,  302 
from  rectal  polypi,  835 
gastric,'  511 

causes  of,  511,  512 
diagnosis  of,  511 

differential,  512 
from  arteriosclerosis,  528 
lavage  in,  198,  204,  513 
mortality  of,  520 
prophylaxis  of,  512 
treatment  of,  512 

by  analgesics,  518 
atropin,  518 
chloroform       water, 

519 
orthoform,  519 
by  enemata,  514 
by  hemostatics,  514 

adrenalin,  271,  517 
bismuth,  517,  520 
blood  -transfusion, 

515 
coagulen,  517 
coagulose,  516 
emetin,  514 
epinephrin,  271,  517 
ergot,  514 
escalin,  518 
gelatin,  515 
' '  hemostatic  serum, ' ' 

516 
hydrastin,  514 
kephalin,  516 
pituitary  extract,517 
silver  nitrate,  518 
stypticin,  515 
thromboplastin,  516 
by  lavage,    513 
medicinal,  514,  519 
operative,  520 
hemorrhoidal,  822 

treatment  of,  823 
intestinal,  511,  747 
diet  in,  172 
enemata  in,  514 
iodin  in,  520 

treatment    of.     See    Hemor- 
rhage, gastric, 
into  bile  ducts,  614 
occult,  in  duodenal  ulcer,  709 
of  pancreas,  631 
Hemorrhoidal  electrode,  Williams',  832 

pessaries,  826 
Hemorrhoids,  821 

age  and  sex  incidence  of,  822 

anatomy  of,  821 

as   a  cause  of  nervous  dyspepsia, 

419 
cleanliness  in,  823 
complications  of,  822 
constipation  as  a  cause  of,  821 


INDEX 


881 


[  [emorrhoids,  development  of,  82 1 
diet  in,  823 
etiology  of,  82 1 
external,  821 
hemorrhage  from,  822 

I  real  nient  of,  823 

internal,  82 1 

pain  of,  ice-bag  (Zweig's)  for,  824 

leeches  for,  825 
pessaries  for,  825,  826 
symptoms  of,  822 
treatnient  of,  822 
bloodless,  827 
by  chrysarobin  suppositories, 

825 
by  electrolysis,  831 
extra-anal,  827 
injection,  828 
mineral  water,  225,  823 
phenol,  828 
quinin  and  urea  hydrochlorid, 

829 
sphincter  stretching  (Verneu- 

il's),  827 
surgical,  832 
Terrell's,  829 
Hepatic  cirrhosis,  590.     See  Cirrhosis, 
insufficiency,  levulose  test  for,  593. 
See  also  Liver, 
lipase  test  for,  592 
phthalein  test  for,  593 
urobilin  test  for,  593 
Hepatitis,  584 

amebic,  emetin  treatment  of,  723 
suppurative,  584 

ipecac  in  prevention  of,  723 
Hepatoptosis,  568,  605 
treatment  of,  605 
Hernia,  epigastric,  as  a  cause  of  nervous 
dyspepsia,  419 
epigastrica,  555 
recti,  845 
Herpes  zoster  in  esophagus,  357 

in  mouth,  318 
Hexosane,  a  hemicellulose,  61 
Hiccough  (singultus  gastricus),  408 

treatment  of,  408 
High  colonic  irrigation,  221 
High-frequency    current    in    digestive 

disorders,  219 
Hill's  esophagoscope,  352 

gastroscope,  352 
Hirschman's  anoscope,  830 

rectal  massage  treatment  of  chron- 
ic constipation,  229 
Hirschsprung's  disease,  790 

Roentgen-ray  diagnosis  of,  148 
Honthin,  277 

Hookworm,  course  of,  to  intestine,  810 
disease,  806 

in  Africa,  808 
anemia  of,  813 
carriers  of,  809 

castor  oil  in  treatment  of,  813 
diagnosis  of,  811 
56 


Hookworm  disease,  distribution  of ,  806 

eosinophilia  in,  SI  1 
leuUo|M'iiia  in,  81 1 
pal  hology  of,  810 
poikilocytosis  in,  810 

polyehroinatophilia  in,  810 
retarded  development  in,  811 
in  South,  806 
symptoms  of,  811 
treatment  of  812 

with  chenopodium,  812 
with  eucalyptus,  813 
with  male-fern,  813 
with  salicylic  acid,  812 
with  thymol,  812 
multiplication  of  the,  809 
penetration  of  skin  by,  810 
Hormonal  in  atonic  constipation,  667 
Hormones,  55,  667 
Hot  applications,  250 
Hour-glass  stomach,  142,  524 
pseudo,  139 

shown  by  Roentgen  ray,  142 
Hunger,  abnormal  (bulimia),  415 
contractions  of  stomach,  64 
pain,  491,  706,  708 
Hydriatic  and  thermic  treatment,  247 
Hydrochloric  acid,  action  of,  54 

in  pancreatic   affections, 
259,  627 
administration  of,  260 
Benedict's  effervescence   test 

for,  88  _ 
bile  secretion  and,  259 
capsule  method  of  taking,  260 
in  chronic  gastritis,  258,  469 
combined,    in    stomach    con- 
tents, 81 
alizarin  test  for,  81 
effect  of,  on  pylorus,  259 
free,  after  Ewald-Boas  break- 
fast, 77 
Riegel  dinner,  77 
and    combined,    phenol- 
phthalein  test  for,  79 
dimethylamidoazobenzol 

test  for,  75,  89 
Gunzburg's  test  for,  76 
normal  solutions  in  titrat- 
ing, 77 
Topfer's  test  for,  80 
Friedrich's  test  for,  89 
in  gastric  diseases,  258 

ulcer,  499 
in  gastrogenic  diarrhea,  674 
gauze  test  for,  89 
in  hyperchlorhydria,  436 
medicinal  effects  of,  258,  436 
pancreatic  function  and,  259 
pepsin  and,  259 
pepsinogen  and,  83 
proteolysis  and,  259 
secretion  in  anomalies  of  men- 
struation, 85 
in  appendicitis,  85 


882 


INDEX 


Hydrochloric  acid  secretion  in   chole- 
lithiasis, 85 
in  chronic  gastritis,  85 
in  nervous  dyspepsia,  85 
in  stomach  contents,  tests  for, 
75 
Hydrocyanic  acid,  dilute,  as  a  gastric 

sedative,  269 
Hydrogen  peroxid  in  gastric  diseases, 

272,  436 
Hydrops  of  gall  bladder,  616 
Hydrotherapeutics,  247 

in  atonic  constipation,  665 
in  gastroenteroptosis,  573 
indications  for,  249 
in  membranous  enteritis,  656 
in  nervous  diarrhea,  681 
Hygiama,  193 
Hymenolepis  nana,  798 
Hyperacidity,    94.     See    also    Hyper- 
chlorhydria. 
alkaline  carbonated  waters  in,  254 
atropin  in,  271 
Carlsbad  water  in,  253 
menstruation  and,  419 
test-diet  stool  findings  in,  131 
with  diarrhea,  438 
with  pain,  439 
Hyperalimentation,  570 

in  gastroenteroptosis,  569 
in  mucous  colitis,  653 
muscular  exercise  and,  571 
in  spastic  constipation,  671 
Hyperchlorhydria,  94,  430 

carbohydrate  digestion  in,  85 
diagnosis  of,  431 
etiology  of,  430 
hyperacidity  of,  438,  439 
pathology  of,  431 
physiotherapeutic  measures  in,  438 
prognosis  of,  432 
symptoms  of,  431 
treatment  of,  dietetic,  432 

fats  and  oils  in,  434 
hygienic,  432 
lavage,  438 
medicinal,  435 
acids,  436 
alkalis  and  alkaloids,  436, 

437,  438 
analgesics,  436 
astringents,  435 
atropin,  435 
peroxids,  436 
Hyperemia  of  liver,  588 
Hyperesthesia  of  esophagus,  384 

of  stomach,  413 
Hyperkinesis,  392 
Hypermotility  of  stomach,  392 
Hyperorexia,  415 
Hypersecretion,  94,  446 
alimentary,  447 

diagnosis  of,  447 
eumydrin  in,  271 
symptoms  of,  447 


Hypersecretion,  alimentary,  treatment 
of,  448 
by  lavage,  448 
medicinal,  448 
alkaline  carbonated  waters  in,  254 
continuous,  441 

diagnosis  of,  443 

by  external  examination 
of  stomach  443 
etiology  of,  442 
prognosis  of,  443 
symptoms  of,  442 
treatment  of,  443 
dietetic,  444 
by  lavage,  446 
medicinal,  445 
by  mineral  waters,  447 
physical,  447 
surgical,  447 
from  vagotonia,  389 
intermittent,  440 
diagnosis  of,  441 
etiology  of,  440 
symptoms  of,  440 
treatment  of,  441 
periodic,  440 
stomach  contents  in,  94 
Hypertrophy,  muscular,  of  esophagus, 

362 
Hypodermic  solutions  in  ampoules,  581 


Ichthyol  in  intestinal  diseases,  281 
Ileal  regurgitation,  684  - 

stasis,  roentgenographic  diagnosis, 
of,  144 
Ileocecal  valve,  insufficiency  of,  783 
Ileum,  carcinoma  of,  764 
kink  of,  559 
stasis  of,  144 
stricture  of,  756 
Ileus,  742 

atropin  in,  754 

chloroform  water  irrigations  in,  227 

diagnosis  of,  745 

external,  742 

from  adhesions,  743 
from  angulations,  etc.,  742 
from    arteriomesenteric    con- 
traction, 743 
from  compression,  743 
internal,  743 

from  ascarides,  774 
from  calculi,  743 
from  fecal  tumors,  744 
from  foreign  bodies,  744 
from  invagination,  743 
from  stricture,  743 
from  torsion,  742 
opium  in,  753 
paralytic,  744 
puncture  in,  753 
spastic,  744 


INDEX 


ss:; 


Ileus,  symptoms  of,  7 1."> 
toxemia  of,  7 17 
treatmenl  of,  7  17 

by  insufflal inn  of  air,  7.7_> 

internal,  7  19 

by  lavage,  750 

medicinal,  753 

nutritional,  750 

l>y  rectal  injections,  741 

irrigation,  752 
surgical,  7  IS 
Incisura   of  stomach  in  gastric  ulcer, 

139 
Incubator  test   for  fecal   fermentation 

and  putrefaction,  116 
Indican  in  urine,  686 
Indol  in  the  intestine,  686 
Infection,  focal,  290 
Influenzal  stomatitis,  302 
Innervation,  contrary,  65 
Insufflation  of  air  in  intussusception, 

228,  752 
Intestinal  absorption,  60,  61 

adhesions,  mud  baths  in,  287 
anastalsis,  63 
antifermentatives,  279 
antiperistalsis,  63 
antisepsis,  oxygen  for,  105 
antiseptics,  279 
astringents,  276 
atony,  massage  in,  208 
bacteria,  growth  of,  686 

Metchnikoff's  tests  with,  685 
volume  of,  686 
carcinoma,  761.    See  Carcinoma' of 

intestine, 
catarrh,  acute,  635 

diagnosis  of,  637 
etiology  of,  635 
feces  in,  637 
from  cold,  635 
from  food,  635 
from  intoxication,  635 
infectious,  635 
of  large  or  small  intestine, 
distinction  between, 
637 
pathology  of,  635 
prognosis  of,  638 
symptoms  of,  636 
treatment  of,  638 

dietetic,  172,  639 
dry,  237 
irrigation,  232 
medicinal,  641,  643 
sea-water,  642 
chronic,  diagnosis  of,  645 
pathology'  of,  644 
prognosis  of,  647 
symptoms  of,  644 
test-diet  stool  findings  in, 

131,  132,  646 
treatment  of,  647 
with  constipation,  650 
agar  in,  650 


Intestinal  catarrh,  chronic,  wit  h  consti- 
pation, diet  III.  ti.'il) 

ionization  in.  ti.'i l 
liquid  pel rolal um  in, 
650 

rest  in,  050 
with  diarrhea.  <'>17 
bismuth  in,  049 
calcium  in,  fi4X,  649 
diet  in,  647,  <>48 
gelatin  injections  in, 

649 
kaolin  in,  649 
mineral     waters     in, 

254,  649 
rest  in,  647 
vaccine  in,  649 
with    hyperacidity,    650, 

651 
with  pain  and  tenesmus, 
651 
dry  treatment  of,  237 
See  also  Intestinal  irritation. 
colic,  783.     See  Enteralgia. 
contents,  normal  movement  of,  64 
digestion,  56,  61 
diseases,  diet  in,  172 
electricity  in,  230 
location  of,  by  test-diet,  173 
milk  in  diet  of,  174 
mineral  waters  in,  254,  649 
opium  in,  274 
purgatives  in,  282 
rectal  massage  in,  229 
treatment  of,  mechanical,  228 
through  the  rectum,  220 
uzara  in,  276 
displacements    and    constipation, 

696 
douche,  228 
dyspepsia,  oxvgen  insufflation  in, 

105 
fermentation     and     putrefaction, 

differentiation  of,  173 
fermentative  dyspepsia,  181 
diet  in,  181 
oxygen  by  the  duodenal 

tube  in,  679 
test-diet  stools  in,  134 
treatment  of,  679 
function,  test  diet  to  determine,  1 12 
gases,  origin  of,  699 
hemorrhage,  511 
intussusception,  743 
irrigation,  232 

antiseptic,  235 
astringent,  236 

heating  apparatus  used  in,  240 
sedative,  236 
technic  of,  233 
with  mineral  waters,  237 
irritation,  pathologic  effects  of,  685 
treatment  of,  232 
dry,  237 
juice,  59 


884 


INDEX 


Intestinal  juice,  calcium  carbonate  in, 
59 
ferments  in,  59 
variation  in  consistency  of,  59 
kinking,  561 

and  colonic  dilatation,  791 
lesions  in  hookworm  disease,  810 
lipoma,  836 

treatment  of,  836 
lymphosarcoma,  766 
pathology  of,  766 
symptoms  of,  766 
treatment  of,  766 
massage,  211 

motility,  carmin  and  charcoal  tests 
of,  128 
Einhorn's  bead  test  of,  129 
movements,  62 

nerve  control  of,  63,  64 
pendulum,  63 
peristaltic,  62 
segmenting,  62 
myoma,  836 

treatment  of,  836 
neoplasms,  benign,  766 

constipating  diet  in,  172 
neuroses,  781 

high-frequency    currents    in, 
219 
obstruction,  742.     See  also  Ileus, 
an  early  manifestation  of,  745 
enemata  to  remove,  227 
etiology  of,  742 
roentgenography  in,  149 
symptoms  of,  745 
treatment  of,  747 
occlusion,  742.     See  Ileus, 
organs  of  perception,  56 
pain,  831.     See  Enteralgia. 
papillae,  836 

treatment  of,  837 
parasites,  794 
paresis,  782 

causes  of,  783 
diagnosis  of,  783 
following  operation,  lavage  in, 
197 
pituitrin  in,  284,  703 
treatment  of,  783 
perforation  by  round  worm,  801 
peristalsis,  62 

effect  of  opium  on,  275 
relation   of   nodal   tissue   to, 

63,  562,  696 
strychnin  as  an  aid  to,  284 
polypi,  835 

radical  removal  of,  835 
protectives,  276,  279 
putrefaction,  687.     See  also  Intes- 
tinal toxemia, 
beverages  in,  180 
combined  indolic  and  saccha- 

robutyric  type  of,  688    * 
diet  in,  174,  178 
indolic  type  of,  686,  687 


Intestinal  putrefaction,  saccharobuty- 
ric  type  of,  687 
toxic  products  of,  686 
reflexes,  chemical  and  motor,  57 
restlessness,  782 
sarcoma,  766,  834 

pathology  of,  766 
symptoms  of,  766 
treatment  of,  766 
sedatives,  274 
spasm,  781 

appearance  of  stools  in,  781 
treatment  of,  781 
stasis,  683 

duodenal  lavage  in,  107 
oral  sepsis  and,  290 
petroleum  jelly  in,  694 
physiology  of,  683 
pyorrhea  and,  260 
treatment  of,  689 
surgical,  697 
stenosis,  enemata  in,  227 

insufflation  of  air  in,  228 
roentgenographic  diagnosis  of, 
148 
strictures,  755.     See  Stricture. 

lavage  in,  759 
tonus,  64 
toxemia,  683 

abdominal  bandages  in,  696 
antiseptic  diet  in,  689 

buttermilk,  690 
carbohydrates,  690 
sour  milk,  690 
whey,  690 
medication  in,  692 
bacterial  growth  in,  684,  686 
betanaphthol  in,  693 
chloramine-T  in,  693 
constipation  of,  694 
course  of,  685 
diagnosis  of,  686 
duodenal  lavage  in,  695 
etiology  of,  683,  684 
hexamethylenamin  in,  693 
ichthyol  in,  693 
indicanuria  in,  686 
lavage  in,  695 
symptoms  of,  688 
treatment  of,  689 

anticonstipation,  694 
antiseptic,  689,  692 
bacterial,  691 
dietetic,  689 
lavage,  695 
medicinal,  692 
surgical,  696 
tuberculosis,  737,  740 
diagnosis  of,  738 
prognosis  of,  738 
test-diet  stool  findings  in,  133 
treatment  of,  739,  741 
dietary,  739 
medicinal,  739 
specific,  740 


i.\i)i:.\ 


885 


Intestinal    tuberculosis,    treatment    of, 
bj  mptomai  ic,  739,  7  10 
tumors,  172,  761,  766 

ulcers,    70.-),    713,    710,    730,    737. 

Set  Ulcer,  duodenal,  and  Ulcers, 

intestinal, 
wall,  pathologic  products  of,   121 

Intestine,  elVect  of  handling,  783 

pendulum  movements  of,  63 

Roentgen-ray  examination  of,  143 

segmenting  movements  of,  62 

short-circuiting  the,  697 

small,   relative  importance  of,  in 
intestinal  diseases,  ISO 
lntra-intestinal  medication,  dry,  237 

powder  blowers,  238 
Intrarectal  treatment  of  intestinal  dis- 
eases, 220 
Intraventricular  electrization,  216 
Intussusception,  743 

hemorrhage  from,  747 

incidence  of,  643 

insufflation  of  air  in,  228,  752 

rectal  irrigations  for,  228 
Invertin,  59 
lodid  salivation,  301 
Iodin  germs,  181 

in  gastric  diseases,  272 
Iodoform  in  diseases  of  mouth,  297 

mass,  preparation  of,  298 
Ionization  in  enteritis,  651 
Iron,  organic,  188 
Irrigating  fluid  for  duodenal  lavage,  106 

tubes,  233,  234 
Irrigation  of  intestine,  227,  232.     See 
also  Intestinal  irrigation. 

of  stomach,  205 
Itching  of  anus,  851 


Jaundice,  febrile,  587.     See  also  Cho- 
langitis and  Cholecystitis, 
serum  treatment  of,  588 

Carlsbad  waters  in,  611 

catarrhal,  607 

development  of,  609 

functional,  609 

hematogenous,  609 

hepatic  cysts  and,  604 

itching  and,  609 

sequelae  of,  609 
Jejunal  carcinoma,  764 

stricture,  756 

ulcer,  712 
Jutte's  apparatus  for  duodenal  lavage, 
104 

duodenal  tube,  100 


Karell  milk-cure  of  dropsy,  163 
Kefir  in  diet,  164 


Kefir,  koumiss,  VOghurl  and  sour  milk, 

comparison  of,  it;.") 

Keith's  nodal  tissue,  63,  561,  696 

Kelly's  proctoscope,  230 

Kidney,  movable,  566 

chronic  appendicitis  and,  768 
palpation  of,  566 
Kinases  in  digestion,  53 
Kinking,  intestinal,  561 
Koumiss  in  diet,  164 
Kuhn's  duodenal  tube,  98 


Lacerations,  obstetric,  nervous  dys- 
pepsia and,  419 
Lacing,  gastroenteroptosis  and,  557 
Lacrimal  glands,  enlargement  of,  330 
Lactase,  59 

Lactic  acid  in  intestinal  diseases,  279 
in  stomach  contents,  82 

Strauss'  test  for,  83 
Uffelmann's  test  for, 
82       . 
Laennec's  disease,  590 
Lane's  short-circuiting  operation,  697 
Lavage,  197 

in  achylia  gastrica,  471 

in  alimentary  hypersecretion,  448 

in  colonic  carcinoma,  766 

in  continuous  hypersecretion,  446 

in  convulsions  from  overeating,  198 

in  diabetes  mellitus,  198 

duodenal,  105.     See  also  Duodenal 

lavage, 
in  eclampsia,  198 
in  enteritis  membranacea,  655 

ulcerative,  733 
in  gastric  atony,  476,  482 
dilatation,  197,  482,  487 
relaxation,  208 
tetany,  198 
gastric  or  colonic,  apparatus  for, 

199 
in  gastritis,  acute,  198,  450,  454 
chronic,  471 
with  mucus,  197,  471 
in  gastrogenic  diarrhea,  677 
in  hematemesis,  198 
in  hemorrhage  from  gastric  ulcer, 

198,  513 
in  hyperchlorhydria,  438 
in  hypersecretion,  448 
in  ileus,  750 

in  intestinal  catarrh,  649 
paresis,  197 
stricture,  759 
toxemia,  695 
medicated,  in  nervous  gastralgia, 

210 
in  meteorism  of  typhoid,  198 
in  motor  insufficiency,  476,  482 
in  nephritis,  198 


886 


INDEX 


Lavage  by  patient,  201.     See  also  Auto- 
lavage. 
in  poisoning,  197 

preceding  gastric  or  intestinal  sur- 
gery, 197 
for  prevention  of  vomiting,  197 
in  pyloric  stenosis,  197,  198 
for  removal  of  gastric  mucus,  197, 

205,  471 
of  stomach,  197 

apparatus  for,  198,  199 
contra-indications  against,  198, 

204 
duration  of,  204 
indications  for,  197 
safety  of,  203 
technic  of,  199,  200 
time  for  giving,  204 
in  vomiting,  197 

of  peritonitis,  198 
postoperative,  197 
with  Aaron's  improved    stomach 

tube,  71 
without  the  stomach  tube,  201 
Law  of  contrary  innervation,  65 
Laxative  diet,  182 
drugs,  284 
agar,  662 

inorganic  salts,  284 
liquid  petrolatum,  664 
phenolphthalein,  286 
Lead  stomatitis,  301 
Leather-bottle  stomach,  546 
Legumes  in  diet  of  gastric  patients,  167 
Legumins,  Hartenstein's,  193 
Leiter's  coiled  tubing,  251 
Lenhartz  treatment  of  gastric  ulcer,  498 
Leontiasis  ossea,  345 
Leprosy  of  mouth,  314 

treatment  of,  315 
Leube's  diverticular  sound,  376 

test  meal  for  testing  gastric  motil- 
ity, 90 
Leube-Ziemssen   treatment   of   gastric 

ulcer,  495 
Leukocytosis  in  acute  appendicitis,  775 
Leukopenia  in  hookworm  disease,  811 
Leukoplakia,  319 

from  glass-blowing,  304 
mouth-washes  in,  320 
oral  carcinoma  and,  342 
radium  in  treatment  of,  320 
removal  of  plaques  of,  320 
Levulose  in  urine,  test  for,  593 
Leyden  and  Ran  vers'  esophageal  bougie 

and  cannula,  371 
Lichen  planus  in  mouth,  317 

treatment  of,  317 
Lingua  geographica,  323 
nigra,  323 
plicata,  326 
Lingual  abscess,  324 
phlegmon,  324 
tonsil,  hyperkeratosis  of,  327 
hypertrophy  of,  326 


Lingual  tonsillitis,  acute,  326 

ulcers,  325 
Linitis  plastica  hypertrophica,  546 
Linseed  poultices,  250 
Lipanin,  194 
Lipase,  56 

tests  for,  592 
Lipoma  of  esophagus,  362 
of  intestine,  836 
of  mouth,  335 
of  rectum,  836 
of  stomach,  555 
Lips,  abscess  of,  334 
carcinoma  of,  342 
congenital  fistulse  of,  333 
eczema  of,  317 

treatment  of,  317 
exfoliative  inflammation  of,  334 
inflammation  of,  334 
acute,  334 
chronic,  334 
Liquid  petrolatum,  laxative  action  of, 
664 
in  rectal  carcinoma,  834 
Liver.  See  also  Febrilis  icterus, Cirrhosis, 
and  Hepatic  insufficiency, 
abscess  of,  584 

symptoms  of,  585 
treatment  of,  586 
acute  affections  of,  584 
angioma  of,  602 
atrophy  of,  acute  yellow,  586 
treatment  of,  587 
brown,  598 
partial,  .598 
red,  598 
carcinoma  of,  600 
chronic  affections  of,  588 
cirrhosis  of,  590.     See  Cirrhosis  of 

liver. 
cysts  of,  602 
diseases  of,  584 
dislocation  of,  568 
echinococci  in,  602 
diagnosis  of,  603 
symptoms  of,  603 
treatment  of,  604 
fatty,  604 

etiology  of,  604 
pathology  of,  605 
treatment  of,  605 
fibroma  of,  602 
floating,  605 

function,  tests  for,  592,  593 
hyperemia  of,  active,  588 
diagnosis  of,  589 
treatment  of,  589 
passive,  589 

symptoms  of,  589 
treatment  of,  590 
inflammation  of,  584 

treatment  of,  584 
neoplasms  of,  600 
neuralgia  of,  605 
parasites  of,  602 


i.\  Di:\ 


887 


Liver,  roentgenography  in  stud]  of,  L49 

sarcoma  of,  60  1 

syphilis  of,  acquired,  599 
diagnosis  of,  600 
symptoms  of,  599 
i  reatmeni  of,  600 

congenital,  599 
tumor  from  echinococci,  60  I 
Loewi's  pupillary  symptom  of  pancrea- 
tic insufficiency,  626 

Ludwig's  angina.  330 

treatment  of,  '■>'■'< I 
Lupus  erythematosus  in  mouth,  :!17 

of  oral  mucosa,  312 
Lymph  glands,  nodiform  and  verru- 
cous, in  mouth,  337 
Lymphangioma  of  mouth,  337 
Lymphoma,  cystic,  of  mouth,  337 

diffuse,  of  mouth,  337 
Lymphosarcoma  of  intestine,  766 


M 


MacMillax's    rectal    tampon    treat- 
ment of  chronic  constipation,  230 
Macroglossia,  326 
Maggot  worm,  803 

Magnesium  peroxid  in  gastric  diseases, 
272 
sulphate  for  draining  gall  bladder 
and  bile  ducts,  105,  612 
subcutaneously,  666 
Malar  mucosa,  affections  of,  334 

carcinoma  of,  344 
Malformation  of  tongue,  322 
Malignant    growths,    intestinal,    761. 
See  also  Carcinoma  and 
Sarcoma, 
constipating  diet  in,  172 
Malleus  in  man,  313 
Maltase,  59 
Maltose,  50 
Mammala,  192 
Mandrake  as  a  cathartic,  286 
Marasmus  and  duodenal  ulcer,  710 
Massage,  208 

abdominal,  212,  214 
in  atonic  constipation,  208,  664 
in  connective-tissue  adhesions,  208 
in  gastric  dilatation,  208,  483 
relaxation,  208 
retention,  208 
in  gastritis,  chronic,  472 
in  gastroenteroptosis,  574 
jn  ileus,  753 
in  intestinal  atony,  208 
of  intestine,  211 

technic  of,  211-213 
and  medicated  lavage  in  nervous 

gastralgia,  210 
in  motor  insufficiency,  477,  483 
in  nervous  dyspepsia,  208,  423 
in  pyloric  stenosis  with  dilatation, 
208 


Massage  in  pylorospasm,  209 

rectal,  in  chronic  constipation,  229 
in  relaxal  ion  of  stomach,  208 
in  retention  of  gast  ric  contents,  208 
of  stomach,  208 

contra-indications  for,  208 
indications  for,  208 
technic  of,  209 
of  sympathetic  uerve  plexuses,  21 1 
vibratory,  211 
in  volvulus,  749 
Matthews'  treatment  of  ulcerative  coli- 
tis, 733 
Maxilke,  adamantoma  of,  345 
carcinoma  of,  346 
chondroma  of,  345 
cysts  of,  345 
odontoma  of,  345 
osteoma  of,  345 
sarcoma  of,  34(3 
Meal.    See  Test  meal. 
Measles,    diseases   of  salivary   glands 
and,  329 
oral  manifestations  of,  301 
Meat  and  gastric  secretion,  53 
composition  of,  160 
hi  diet,  159 
digestibility  of,  161 
extracts,  194 

composition  and  relative  val- 
ues of,  195 
preparation  of,  160 
restriction  of,  160 
Meats,  canned,  160 

in  constipating  diet  of  intestinal 

diseases,  179 
light  and  dark,  159 
raw,  rare  and  smoked,  in  gastric 
diseases,  160 
trichinosis  and,  160 
salted,  160 
Mechanical    treatment    of    intestinal 

diseases,  228 
Meckel's  diverticulum,  742 
Medication  in  gastric  diseases,  258 

in  intestinal  diseases,  274 
Medicinal  exanthems,  301 
Megacolon,  congenital,  790 
Melena  in  infants,  relation  of  duodenal 

ulcer  to,  710 
Meltzer's  sign  of  acute  appendicitis,  i  70 
Menstrual  anomalies,  HC1  secretion  in, 
85 
nervous  dyspepsia  and,  419 
Menstruation,  gastric  acidity  and,  419 
Mercurial  stomatitis,  299 
Merycism,  405 
Metagen,  159 

Metchnikoff  on  Bulgarian  milk,  165 
Metchnikoff's  tests  with  intestinal  bac- 
teria, 685 
Meteorism,  698 

hormonal  in,  667,  703 
large  enemata  in,  228 
physostigmin  in,  703 


INDEX 


Meteorism,  pituitary  extract  in,  703 
Metric  weights  and  measures,  862 
Microscopic   examination   of  stomach 

contents,  92 
Mikulicz's  disease,  330 
Milk,  boiled,  for  young  patients,  176 
Bulgarian,  165 

in  catarrh  of  small  intestine,  176 
compared  with  artificial  foods,  189 
cure  of  dropsy,  163 
in  diet,  162,  175 
in  gastric  diseases,  175 
gastric  secretion  and,  53 
in  intestinal  diseases,  174,  175 
modification  of,  163 
by  boiling,  176 
by  lime  water,  163 
by  salicylic  acid,  176,  178 
preparations,  176 

Gartner's  fat  milk,  194 
kefir,  194 
koumiss,  194 
vegetable  milk,  194 
Voltmers  mother's  milk,  194 
yoghurt,  164 
protein  preparations,  191 
Schmidt's  method  of  reducing  the 

irritating  effects  of,  176 
somatose,  192,  277 
sour,  kefir,  etc.,  165 
sugar,    fermentation    of,    in    the 

bowel,  175 
vegetable,  194 
Mineral  baths,  256 

radio-activity  of,  257 
oil  as  a  laxative,  582,  664 
water  cures,  254,  823 
waters,    168,  247,  252,   582.     See 
also  Carlsbad, 
in  acute  gastritis,  253 
alkaline  carbonate,  253 

chlorin,  252 
bitter,  254 

mode  of  action  of,  255 
in  chronic  gastritis,  255 
gastrorrhea,  447 
intestinal  catarrh,  254, 649 
ferruginous,  254 

in  chronic  diarrhea,  256 
in  gastric  diseases,  167 
in  motor  insufficiency,  477,  483 
purgative,  action  of,  254 

constipating  effect  of,  255 
time  for  taking,  254 
sodium  chlorid,  253 

effect  of,  on  gastric  secre- 
tion, 253 
Miner's  anemia,  806 
Miostagmin  reaction  in  gastric  carci- 
noma, 544 
Miserere,  742 

Mixed  nutritive  preparations,  193 
Morgan's    modification    of    Einhorn's 

duodenal  alimentation,   502 
Morphin  as  an  intestinal  sedative,  274 


Motility    of    colon,    roentgenographic 
study  of,  145 
of  intestine  shown  by  bead  test, 
129 
by  carmin    or    charcoal, 
128 
of  stomach,  disturbance  of,   140. 
See  Motor  function, 
shown  by  Roentgen  ray,  140 
Motor  function  of  stomach,  50,  90 
chlorophyl  test  of,  91 
Einhorn's   bead  test   of, 

129 
Leube's  test  meal  and,  90 
insufficiency,  95,  473 

of  first  degree  (atony),  473 
diagnosis  of,  474 
etiology  of,  473 
symptoms  of,  474 
treatment  of,  475 
dietetic,  475 
by  lavage,  476, 

482 
medicinal,  477 
physical,  477 
with  mineral 
waters,  477 
of  second  degree  (dilatation), 
478 
bandages  in,  483 
diagnosis  of,  480 
drugs  in,  483 
etiology  of,  478 
galvanism  in,  483 
lavage  in,  482 
massage  in,  483 
mineral    waters    in, 

483 
rectal     alimentation 

in,  482 
subcutaneous   nutri- 
tion in,  482 
symptoms  of,  479 
thirst  of,  481 
treatment  of,  481 
shown  by  food  remnants  in  the 
stomach,  95 
neuroses,  387 

treatment  of,  391 
Mould  fungi  in  the  stomach,  92 
Mouth,  actinomycosis  of,  316 
adenoma  of,  340 
anatomy  of,  289 
angioma  of,  336 
bacteria  in,  289,  700 
burns,  303,  304 
carcinoma  of,  342 

relation  of  leukoplakia  to,  342 
cysts  of,  336,  337,  338,  339 
diseases,  289 

cauterization  in,  298 
in  constitutional  infectious  dis- 
eases, 301 
non-infectious     diseases, 
302 


INDEX 


889 


Mouth  diseases,  feeding  in,  298 

from  liisinul  h,  300 
from  bromids,  30] 
from  general  intoxications,299 

from  iodids,  301 

from  lead,  301 

from  mercury,  299 

prophylaxis    and     treat- 
ment of,  300 

from  silver,  301 

from  yellow  phosphorus,  301 

general  treatment  of,  293 

in  glass-blowers,  304 

iodoform  in,  297 

local  anesthetics  in,  299 

nutrition  of  patients  with,  298 

occupation  and,  295 

potassium  chlorate  in,  297 

secretory,  321 

trophic,  321 

vasomotor,  321 
endothelioma  of,  340 
erosions,  303 

etiology  and  treatment  of,  303 
exanthems,  301 
fibroma  of,  335 
glanders  of,  313 
hemangioma  of,  336 
herpes  of,  318 
hygiene  of,  296 
leprosy  of,  314 
lichen  planus  of,  317 
lipoma  of,  335 
lupus  of,  312 

erythematosus  in,  317 
lymphangioma  of,  337 
lymphoma  of,  337 
manifestation  of  measles  in,  301 
myxoma  of,  336 
nervous  affections  of,  320 
papilloma  of,  340 
parasites  in,  320 
pemphigus  of,  317 
phlegmons  of,  324,  330 
ranula  of,  339 
in  scarlet  fever,  301 
scleroma  of,  315 
skin  diseases  in,  316 
sore,  in  chlorosis,  302 
strumas  of,  339 
syphilis  of,  309 
primary,  309 
secondary,  310 
tertiary,  311 
telangiectasia  of,  336 
tuberculosis  of,  312 
tumors  of,  benign,  335,  345 

malignant,  341,  346 
typhoid  ulcers  in,  302 
urticaria  in,  318 
vaccinia  in,  302 
varicella  in,  302 
variola  in,  302 
Mouth-washes  in  gangrenous  stomati 
tis,  306 


Mouth-washes  in  leukoplakia,  :;_'(i 

recommended,  295,  296 
Movable  kidney,  appendicitis  and,  768 

palpal  ion  of,  OIK; 
Mucous  colitis,  652 

membrane  in  stomach  contents,  9  1 

Mucus  from  small  and  large  intestine, 
differentiation  of,  121 

in  stomach,  lavage  for  removal  of, 

197 
in  stool,  121 
Mud  baths  in  gastric  neuroses,  257 

in  intestinal  adhesions,  257 
Muller-Schlecht    test    for  trypsin,   125 
Murphy  drip,  239 

in  acute  appendicitis,  774,  778 
in  duodenal  feeding,  502 
in  severe  intestinal  catarrh, 
641 
Murphy's  sign  of  cholelithiasis,  619 
Muscle  remnants  in  feces,  120 
Muscular  exercise  and  hyperalimenta- 
tion, 571 
relaxation  of  stomach,  massage  in, 
208 
Mutase,  191 

Myasthenia  gastrica,  473 
Myers  cardia  dilator,  397 
Myiasis  intestinalis,  820 
Myoma  of  esophagus,  362 

of  rectum,  836 
Myxoma  in  mouth,  336 
Myxosarcoma,  maxillary,  346 


N 


Narcotics  in  intestinal  diseases,  274 
Nasal  feeding,  299 
Naunyn's  sign  of  cholelithiasis,  619 
Nausea,  nervous,  415 

treatment  of,  415 
Necator  americanus,  806 
Necrosis  of  pancreas,  631 
Neoarsphenamine,  534 
Neoplasms  of  bile  ducts  and  gall  blad- 
der, 614 
of  esophagus,  362 
of  intestine,  761,  766 
of  fiver,  600,  610 
of  mouth,  336 

of  stomach,  537,  553.     See  Stom- 
ach. 
Nephritis,  gastric  lavage  in,  198 
Nephroptosis,  565 
Nerve,  facial,  paralysis  of,  320 

plexuses  accessible  by  massage,  214 

of  intestine,  64 
supply  of  stomach,  52 
Nervous  affections  of  intestine,  392,  781 
of  mouth,  320 
of  stomach,  392 
anorexia,  418 

diarrhea,  test-diet  stools  in,   134, 
681 


890 


INDEX 


Xervous  dyspepsia,  418.  See  Dyspepsia, 
nervous, 
eructation,  401.     See  Aeropliagy. 
nausea,  415 

system,  autonomic,  388 
vegetative,  387,  390 
vomiting,  403 
Neuralgia  of  liver,  605 
of  stomach,  410 
of  tongue,  321 
Neurasthenia  gastrica,  418 

gastroenteroptosis  and,  562 
Neuritis  from  lack  of  vitamin,  157 
Neuroses  of  esophagus,  384 
of  intestine,  781 
motor,  387 
sea  baths  in,  257 
secretory,  430,  440 
sensory,  410 
of  stomach,  387 

and  intestine,   treatment   of, 

391 
electricity  in,  215 
eye-strain  and,  418 
gastric  contents  in,  94 
Nicotin  in  gastric  diseases,  271 
Nitroglycerin  as  a  gastric  sedative,  269 
Nodal  tissue  in  intestine,  64,  561 
Nodes,  peristaltic,  562,  696 
Noma,  306 

treatment  of,  307 
Normal  solutions  in  quantitative  anal- 
ysis of  stomach  contents,  77 
Nothnagel's  contribution  to  fecal  exam- 
ination, 112 
Nuclei,  effect  of  pepsin,  trypsin  and 
erepsin  upon,  126 
in  feces,  significance  of,  126 
pancreatic  digestion  of,  624  . 
test  of  Adolf  Schmidt,  126 
Nurslings  and  oral  antiseptics,  297 
Nutrient  enemata,  243 
Nutrition  of  patients  with  mouth  dis- 
eases, 298 
subcutaneous,  482 
technic  of,  in  gastroenteroptosis, 
571 
Nutritive  preparations.     See  Food  pre- 
parations. 
Nutritive-Heyden,  192 
Nutrole,  194 
Nutrose,  191 


Obstruction   of    common   bile    duct, 
signs  of,  109 
of  intestine,  742 

roentgenography  in,  149 
Occult  blood  in  feces,  benzidin  test  for, 
123 
phenolphthalein  ring  test 
for,  124 
in  intestinal  tuberculosis,  738 


Occupation  and  mouth  diseases,  295 
Ochsner's    method    of    treating    acute 

appendicitis,  774 
Odda,  193 

Odontoma  of  maxillae,  345 
Oil  enemata,  223 

enemator,  Roberts',  225 
Zweig's,  224 
Olive  oil  agar  tubes,  102 

in  gastric  diseases,  273 
Onions  in  gastric  diseases,  166 
Opium  as  an  evacuant,  283 
in  ileus,  753 

in  intestinal  diseases,  274,  275 
preparations  in  intestinal  disease, 
275 
Oral  antiseptics  for  nurslings,  297 

effects  of  antipyrin,  quinin,  phen- 
acetin,    and   acetylsahcylic 
acid,  301 
of  influenza,  302 
of  measles,  301 
of  paratyphoid  fever,  302 
of  rubeola,  302 
of  scarlet  fever,  301 
of  typhoid  fever,  302 
of  vaccinia,  302 
of  varicella,  302 
of  variola,  302 
lesions,  traumatic,  304 

treatment  of,  304 
lupus,  312 

local  treatment  of,  313 
sepsis,  290 

constitutional    diseases    and, 

"291 
duodenal  ulcer  and,  706 
gastric  ulcer  and,  489 
organic  infections  and,  292 
See  also  Mouth. 
Orexin  in  gastric  diseases,  267 
Orthoform-new  as  a  gastric  anodvne, 

270 
Osteoma  of  maxillae,  345 

of  mouth,  336 
Otitis  from  parotitis,  329 
Oxygen   insufflation    as    an   intestinal 
antiseptic,  105,  679 
in  intestinal  fermentative  dyspep- 
sia, 679 
Oxyuris   vermicularis,    803,    804.     See 
also  Thread  worm. 


!  Packs,  cold,  248 

warm,  249 
Pain  of  acute  gastritis,  454 

of  duodenal  ulcer,  706,  707,  708 
gastric,  266,  270.     See  Gastralgia. 
of  gastric  erosions,  522 
hyperesthesia,  413 
ulcer,  490,  491 
of  hemorrhoids,  824 


INDEX 


891 


Pain,  bunger,  191,  706,  708 
of  hypersecrel ion,  I  \2 
of  ileus,  7  15 

of  intestinal  obstruction,  7  15 

ulcer,  70ti 
sign  of  appendicil is,  acute,  77<> 
chronic,  772.  77". 
of  pancreatic  disease,  627 
l'aius  in  chronic  intestinal  catarrh  with 

diarrhea.  6 15 
dysenteric,  epinepluin  in,  726 

local   and   internal    treatment 
for,  72ii 
of  sarcoma,  553 
Palatal  carcinoma,  3  1 1 
effects  of  rubeola,  302 
gummata,  31 1 
ulcers.  :!()4 

in  typhoid  fever,  302 
Palefski's  duodenal  tube,  100 
Pancreas,  diseases  of,  623.     See  Pan- 
creatic and   Pancreatitis. 
inflammation  of,  623.     See  Pancre- 
atitis, 
roentgenography  in  study  of,  149 
Pancreatic  affections,  action  of  hydro- 
chloric acid  in,  259,  627 
diet  in,  627,  629 
internal  treatment  of,  627,  629 
calculi,  633 
carcinoma,  roentgenography  and, 

149 
cysts,  632 

laparotomy  in,  632 
roentgenography  in,  149 
digestion  of  nuclei,  624 
ferments,  57 
fistula,  antidiabetic  diet  in,  630 

surgery  in,  63 1 
function,  duodenal  contents  and, 
120 
HC1  and,  259 
Sahlf s  glutoid  test  of,  129 
hemorrhage,  631 
infantilism,  634 

insufficiency,    epinephrin   test   of, 
626 
pupillary  symptoms  of,  626 
juice,  57 
necrosis,  631 

obstruction,  pilocarpin  in,  630 
preparations,  263 
secretion.  57 

anomalies  of,  103 
determination  of,  101,  102,103 
effect   of   carbohydrates   and 
proteins  on,  629 
of  hydrochloric  acid  on, 
259 
tumors,  633 
Pancreatin,  262 

digestive  properties  of,  262 
preparations  in  chronic  pancreati- 
tis, 628 
Pancreatitis,  acute,  628 


Pancreatitis,  acute,  percussion  sign  of, 
629 

treat  liienl    ot".  628 

chronic,  623 

carbohydrates  in,  <'.js 
diagnosis  of,  62 1 

by  <  iammidge  test,  626 
by  fa  i  test,  625 
l>v  Loewi's  test,  626 
by  oil  test  breakfast,  626 
by  percussion,  629 
by  protein  test,  62 1 
by  starch  test,  625 
etiology  of,  62  I 
pathology  of,  624 
prognosis  of,  627 
symptoms  of,  623 
test-diet  stool  in,  62  I 
treatment  of,  627 
dietetic,  627 
surgical,  628 
use  of  duodenal  tube  in,  625 
duodenal  contents  in,  109 
pancreatic  secretion  and,  109 
Pancreon,  263 
Pantopon,  275 

Papaverin  as  an  antispastic,  27o 
Papayotin,  263 
Papilla?  of  rectum,  836 
Papilloma  in  esophagus,  362 
of  mouth,  340 
mucous,  555 
Paracentesis  in  ascites,  595 
Paraffin  enemata,  225 
Paralysis  of  esophagus,  385 
of  facial  nerve,  320 
of  rectum,  849 
Parasites  of  bile  ducts,  616 
in  esophagus,  361 
of  intestine,  794 
of  liver,  602 
in  mouth,  320 
Paratyphlitis,  767 
Paratyphoid  fever,  palatal  ulceration 

in,  302 
Paresis  of  intestine,  849 

and  paralysis  of  rectum,  849 
Parotitis,  epidemic,  329. 

treatment  of,  329 
ulcerous,  329 
Parulis,  331 

Passio  ihaca,  742.     See  Ileus. 
Pathogenesis  of  gastric  ulcer,  cholecys- 
titis, etc.,  292 
Pathologic  changes  reflected  in  gastric 
secretion,  94 
food  remnants,  119 
products  of  the  intestinal  wall,  121 
stools  and  their  significance,  119 
Pawlow's  experiments  in  digestion,  52, 

54,  56 
Peas  in  the  diet  of  gastric  patients,  K'., 
Pegnin,  163 

Pemphigus  in  esophagus,  357 
of  oral  mucosa,  317 


892 


INDEX 


Pendulum  movements  of  intestine,  63 
Pentosane,  a  hemicellulose,  61 
Pepsin,  64,  65 

administration  of,  259,  262 
determination  of,  83 

by  gelatin  test,  50,  84 
by  Jacoby-Solms  method,  83 
by  Mett  test,  84 
by  ricin  test,  83 
in  gastric  disorders,  674 
hydrochloric  acid  and,  258,  259 
precautions  in  administering,  259 
unit,  84 
Pepsinogen   and   pepsin,    examination 
for,  83 
relation  of  HC1  to,  54,  83 
Peptic  digestion,  end  products  of,  54 

ulcer  of  esophagus,  360 
Peptids,  54 

Peptone  preparations,  188 
food  value  of,  189 
Peptones,  test  for,  85 
Perforating  gastric  ulcer,  488,  509 
Perigastritis,  524 
causes  of,  524 
diagnosis  of,  525 

roentgenography  in,  525 
forms  of,  525 

hour-glass  stomach  in,  524 
prophylaxis  of,  526 
symptoms  of,  525 
treatment  of,  526 
Perineal  lacerations,  nervous  dyspepsia 

and,  419 
Periostitis  alveolaris  dentalis,  331 

treatment  of,  332 
Perisigmoiditis,  acute,  785,  789 
appendicitis  and,  789 
chronic,  790 

diverticulitis  and,  785,  789 
etiology  of,  785 
symptoms  of,  788 
treatment  of,  790 
ulcerative,  789 
Peristalsis,  effect  of  opium  on,  274 

of  intestine,  62.    See  also  Intestinal 

peristalsis, 
of  stomach,  51,  140 

in  duodenal  ulcer,  709 
Peristaltic  nodes,  63,  561,  696 
restlessness,  782 
rush,  63 
stimulants,  172 
unrest  of  stomach,  392 

treatment  of,  393 
waves,  double,  139 
Peristaltin  in  atonic  constipation,  667 
Peritoneal  inflation  in  roentgenography, 

150 
Peritonitis,  circumscribed,  767 
Perityphilitis,  767 
Permeability  of  pylorus,  91 
Pernicious  anemia,  duodenal  contents 
in,  110 
hookworm  disease  and,  811 


Pernicious  anemia,  mouth  affections  in, 

302 
Peroxids  in  intestinal  diseases,  230 
Pessaries,  hemorrhoidal,  825,  826 
Petrissage,  210,  213 
Petrolatum,  liquid,  in  constipation,  582 
664 
in  gastroenteroptosis,  582 
in  rectal  carcinoma,  834 
Petroleum  jelly  in  intestinal  stasis,  694 
Pharyngitis,  acute,  346 

chronic,  346 
Pharynx,  affections  of,  346 
Phenacetin,  occasional  oral  effects  of, 

301 
Phenol  in  gastric  diseases,  272 

treatment  of  hemorrhoids,  823 
Phenolphthalein  as  a  laxative,  286 
ring  test  for  occult  blood,  124 
test  for  total  acidity  of  stomach 
contents,  79 
Phlegmonous  esophagitis,  356 
gastritis,  457 
processes  of  tongue,  324 
Phlegmons  of  buccal  fundus,  330 
Phosphorus  stoma titis,  301 
Phrenoptosis,  560 
Physiology  of  digestion,  49 
Physostigmin  as  an  evacuant,  283 
Piles,  821.     See  Hemorrhoids. 
Pilocarpin  in  gastric  diseases,  271 
in  sympathicotonia,  392 
vs.  atropin,  271 
vs.  epinephrin,  390 
Pineapple  juice  as  a  proteolytic,  263 
Pinworms,  803 

appendicitis  and,  767 
Pituitary  extract  in  flatulence,  703 
in  hemorrhage,  517 
in  ileus,  754 

in  intestinal  paresis,  284,  703 
in  meteorism,  703 
Plaques  of  leukoplakia,  appearance  of, 
319 
removal  of,  320 
of  lingua  geographica,  323 
opalines,  310 
syphilitic,  in  mouth,  310 
Plasmon,  192 
Pneumatosis  (drum-belly),  403 

treatment  of,  403 
Poikilocytosis  in  hookworm  disease,  810 
Poisoning,  alkali,  fatality  of,  357 
lavage  in,  197 
lead,  stomatitis  from,  30 1 
mercurial,  oral  effect  of,  299 
prophylaxis  of,  300 
treatment  of,  300 
phosphorus,  stomatitis  and  abscess 

from,  301 
sulphuric  acid,  fatality  of,  357 
Polychromatophilia  in  hookworm  dis- 
ease, 810 
Polyneuritis,  rice  diet  and,  157 
Polypi,  mucous,  555 


/.\  I) EX 


s'.i:; 


Polypi,  rectal,  835 
Polyposis  reel i,  836 
Polysaccharids,  184 

Postoperative  obstructions,   roentgen- 
ography in,   149 
Potassium  chlorate  in  mouth  diseases, 

207 
Potato  poultices,  250 

remnants  in  stool,  121 
Potatoes  as  a  food  for  gastric  patients, 
166 
in  intestinal  diseases,  1S2 
Pot-belly  in  hookworm  disease,  811 
Poultices,  linseed,  250 

potato,  250 
Powder  blowers,  inlra-intestinal,  238 
Pregnancy  as  a  cause  of  gastroenter- 
optosis,  557 
as  a  remedy  forgastroenteroptosis, 

581 
gingivitis  in,  303 
Priessnitz  bandage,  250 
Procidentia  recti,  845 
Proctitis,  841 
chronic,  842 
diagnosis  of,  841 
etiology  of,  841 
hot  water  in,  842 
symptoms  of,  841 
treatment  of,  842 
surgical,  843 
symptomatic,  842 
Proctoclysis,  239 

apparatus,  240,  245 

continuous,  Young's  apparatus  for, 

242 
Elbrecht's  heating  apparatus  for, 

240,  242,  243 
use  of  thermos  flask  in,  242 
Proctoscope,  Kelly's,  230 
Proctospasm,  etiology  of,  848 
symptoms  of,  848 
treatment  of,  849 
dilatation,  849 
galvanization,  849 
refrigeration,  849 
Prolapse  of  rectum,  845 
Propeptone,  test  for,  85 
Prosecretin,  57 
Proteal,  550 
Protectives      in     intestinal     diseases, 

279 
Protein,  absorption  of,  60 

examination  of  feces  for,  117 
limitation  of,  in  chronic  pancreati- 
tis, 627 
in  food  cures,  571 
milk-salt-cocoa,  193 
preparations,  animal,  187 
from  eggs,  192 
from  milk,  191 
vegetable,  191 
soluble,  in  stool,  121 
Proteolysis,  HC1  and,  259 
pepsin  and,  259 


Proteolytic  action  of  pineapple  juice, 

263 
Protogen,  192 

Protozoa  in  stomach  contents,  92 
Pruritus  ani,  851 

anal  dilatation  in,  s.V, 

plugs  in,  N56 
bacterial  vaccines  in,  856 
Ball's  operation  in,  857 
calomel  for  itching  of,  853 
diet  in,  853 
dry,  852  * 
etiology  of,  851,  852 
hot  applications  in,  854 
local   and   general   conditions 

associated  with,  852 
moist,  852 

ointments  for,  853,  854,  855 
pathogenesis  of,  851 
quinin  and  urea  hydrochlorid 

in,  855 
Roentgen  ray  in,  856 
streptococci  in,  852,  856 
thread  worm  and,  803 
tincture  benzoin  in,  853 
treatment  of,  853 
ulceration  in,  851 
of  jaundice,  609 
Psychic  initiation  of  gastric  secretion, 

52,  67 
Psychogenic  nervous  diarrhea,  680 
Psychotherapeutics  in  aerophagy,  402 
in  akoria,  416 
in  cardiospasm,  396 
in  rumination,  406 
Ptosis  and  appendicitis,  768 
Ptyalin,  action  of,  50 
Ptyalism,  330 
Pumpernickel,  165,  184 
Pupillary  symptom  of  pancreatic  in- 
sufficiency, 626 
Purgative  drugs,  284 

effect  of  mineral  waters,  254,  255 
Purgatives,  282 

indications  for,  282 
the  mildest,  284 
Pus  in  intestinal  contents,  122 

in  stomach  contents,  66 
Putrefaction  of  feces  a  peristaltic  stimu- 
lant, 172 
Pyloric  closure,  cicatricial,  lavage  in, 
198 
dilator,  Einhorn's,  400,  485 
function,  vertebral  pressure  and, 

211,  405 
insufficiency,  demonstration  of,  96 

treatment  of,  407 
obstruction,   roentgenography   in, 

142 
patency,  blue  bead  to  demonstrate, 
91 
duodenal   bucket  to   demon- 
strate, 91 
stenosis,  96 

congenital,  510 


894 


INDEX 


Pyloric  stenosis,  dilatation  of,  484 

fibrolysin  in,  484 

in  gastric  ulcer,  509 

hypertrophic,  509 

lavage  in,  197,  198 

massage  in,  208 

Ramnistedt  operation  in,  510 

pseudo,  in  babies,  510 

stomach  contents  in,  96 

syphilitic,  533 

thiosinamin  in,  484 

treatment  of,  484 
surgical,  485 
Pylorospasm,  398 

benzyl  benzoate  in,  400 
diagnosis  of,  399 

with  delineator  string,  399 

with  duodenal  bucket,  399 
dilatation  of,  400 
electricity  in,  215 
epinephrin  in,  400 
massage  in,  209 
mud  baths  in,  257 
oil  treatment  of,  400 
papaverin  in,  400 
tabes  and,  105 
Pylorus,  closure  and  relaxation  of,  52 
effect  of  hydrochloric  acid  on,  259 
fifth  dorsal  vertebra  and,  66 
permeability  of,  91 
Pj'orrhea  alveolaris,  332 

treatment  of,  332 
intestinal  stasis  and,  290 
in  diabetes,  303 
salivalis,  327 
in  tabes,  303 


Quinin,  occasional  oral  effects  of,  301 
Quinsy,  347 


R 


Racahotjt,  194 

Rachitis  a  \atamin-deficiency  disease, 

158 
Radishes  in  gastric  diseases,  166 
Radium  in  carcinoma  of  esophagus,  364 
of  rectum,  834 
of  tongue,  550 
instability  of,  257 
in  leukoplakia,  320 
Rammstedt  operation,  510 
Ranula,  339 

Ratowski's  funnel  pessary  for  hemor- 
rhoids, 826 
Reaction  of  stomach  contents,  deter- 
mination of,  75 
Rectal    carcinoma,    832.     See    Carci- 
noma of  rectum, 
constipation  (dyschezia),   146 
dilator,  Roberts',  839 
Rosenberg's,  840 


Rectal  diseases,  821 
electrization,  230 
electrode,  Boas',  231 

Zweig's,  23 i 
friction  in  chronic  constipation, 228 
hemorrhage.     See  Hemorrhoids, 
inflammation, '841.     See  Proctitis, 
irrigating  tube,  Rosenberg's,  234 
Wolbarst's,  234 
Zweig's,  233 
irrigation  by  patient,  222 
massage  in  chronic  constipation, 

229 
myoma,  836 
papillae,  836 

paresis  and  paralysis,  849 
cause  of,  849 
diet  in,  849 
treatment  of,  849 
polypi,  835 

prognosis  of,  835 
treatment  of,  835 
prolapse,  845 

development  of,  845 
ergotin  in,  846 
icicle  in  treatment  of,  847 
massage  of  sphincter  in,  846 
reduction  of,  846,  847 
symptoms  of,  846 
treatment  of,  846 
internal,  846 
nutritional,  846 
surgical,  847 
truss  support  in,  847 
refrigerator,  848 
sarcoma,  834 
strictures,  837 

bougies  in,  838 

diagnosis  of,  837 

dilatation  of,  839,  841 

etiology  of,  837 

malignant  and  non-malignant, 

distinction  between,  838 
symptoms  of,  837 
treatment  of,  838 
tampons  in  chronic  constipation, 

230 
tips,  hard-rubber,  240 
truss,  847 
tube,  220,  221 
tumors,  benign,  835 
malignant,  832 
ulcers,  843.     See  Ulcers  of  rectum. 
Rectum,  diseases  of,  821.     See  Rectal. 
Redundant  sigmoid,  560 
Reflex  nervous  diarrhea,  680 
Refrigerator,  anal,  824 

rectal,  848 
Regurgitation  from  stomach,  406 

of  stomach  contents,  72 
Rehfuss  gastroduodenal  tube,  78 
Rennin,  56 

qualitative  test  for,  84 
zymogen  test  for,  84 
Resorcinol  in  gastric  diseases,  272 


INDEX 


895 


Retarded   developmenl    in   hookworm 

disease,  811 
Retention  of  gastric  contents,  massage 

in,  208 
Retropharyngeal  abscess,  348 
Rhizotomy  in  treatment  of  gastralgia, 

412 
Kill,  fluctuating,  63 
Rice  as  an  article  of  diet,  Hit) 
diet  and  polyneuritis,  157,  161 
injured  by  "polishing,"  106 
vitamin  in,  157 
Roberts'  oil  enemator,  225 

rectal  dilator,  839 
Roborat,  191 

Roentgen     fluoroscopy,     manipulation 
during,  135 
in  sigmoidal  loops,  148 
Roentgen-ray  examination,  135 
of  esophagus,  136 
of  intestine,  143 
of  stomach,  138 
location  of  swallowed  teeth,  377 
in  pruritus  ani,  856 
treatment  of  carcinoma,  550 
Roentgenography  in  appendicitis,  145, 
147 
in  atonic  constipation,  661 
barium  in,  145 

or  bismuth  in,  135 
bismuth  in,  137,  138,  139 
in  callous  gastric  ulcer,  141 
in  cardiospasm,  137,  396 
in  cecal  volvulus,  147 
in  cholecystitis,  150 
in  colonic  carcinoma,  145 
dilatation,  148 
stasis,  147 
in  duodenal  ulcer,  143 
in  enlargement  of  liver,  149 
in  enteroliths,  743 
in  esophageal  dilatation,  137 

spasm,  137 
in  examination  of  appendix,  147 
of  esophagus,  136 
of  colon,  144 
of  intestine,  143 
of  stomach,  138 
in  gall-bladder  disease,  149 
in  gastroenteroptosis,  564 
in  ileal  stasis,  144 
in  intestinal  carcinoma,  764 

distention    and    obstruction, 

149 
spasm,  669 

stenosis,  148,  756,  757 
tumors   by   outlining  spleen, 
150 
in  pancreatic  carcinoma,  149 

cysts,  149 
in  perigastritis,  525 
peritoneal  inflation  in  connection 

with,  150 
in  pyloric  obstruction,  142 
in  rectal  constipation,  146 


Roentgenography  in  spastic  constipa- 
tion, 669 
showing  acute  splenic  flexure,  1 l'> 
appendix,  L45 
atony  of  stomach,  1  It) 
carcinoma  of  esophagus,  138 

of  stomach,  142 
cardiac  stricture.  137 
cardiospasm,  1M7,  396 
cecum  mobile.  1  In 
coloptosis,  146 

deformity  of  duodenal  cap,  143 
deviation  of  colon,  146 

of  sigmoid,  148 
dilatation  of  stomach,  140 
diverticulum  of  esophagus,  138 
form  of  colon,  144,  145 
of  rectum,  146 
of  stomach,  138,  139 
gallstones,  150 
gastric  ulcer,  141 
gastroptosis,  139 
Hirschsprung's  disease,  148 
hour-glass  stomach,  142 
incompetency  of  ileocecal  valve 

144,  148 
intestinal  stenosis,  148 
motility  of  stomach,  51,  140 
position  of  colon,  145 
pyloric  obstruction,  142 
salivary  calculi,  328 
sigmoidal  adhesions,  148 

diverticulitis,  148 
spastic  constipation,  146 
tonicity  of  colon,  146 
tonus  of  stomach,  140 
in  volvulus,  147 
Rosenberg's  powder  blower,  238 
rectal  dilator,  840 

irrigation  apparatus,  234 
Rosenheim's  esophageal  syringe,  354 

tube  for  stomach  douche,  205 
Rose's  adhesive  plaster  belt,  579 
Round- worm,  800 

chenopodium  in  treatment  of,  802 
diagnosis  of,  800 
intestinal  perforation  by,  801 
santonin  in  treatment  of,  802 
symptoms  of,  800 
treatment  of,  801 
Rovsing's  sign  of  chronic  appendicitis, 

772 
Rubeola,  faucial  and  palatal  effects  of, 

302 
Rub-off,  the,  247 
Rumination,  405 

psychic  treatment  of,  406 
Russell's  emulsion,  194 


Saccharin,  167 

Saccharobutyric     type     of     intestinal 
putrefaction,  687 


896 


INDEX 


Sahli's  desmoid  test  for  gastric  secre- 
tion, 90 
glutoid  capsule  test  of  pancreatic 
function,  129 
Salicylates  in  gastric  diseases,  272 
Salicylic  acid  in  intestinal  diseases,  280 

milk,  176 
Saline  solutions,  absorption  of,  61 
Saliva,  two-fold  action  of,  49 
Salivary  calculi,  328 
digestion,  49 
ducts,  diseases  of,  327 
glands,  actinomycosis  of,  329 
diseases  of,  328 

in  general  affections,  329 
enlargement  of,  330 
syphilis  of,  329 
Salivation  from  bromids,  301 
from  iodids,  301 
from  mercury,  299 
from  paralysis  of  facial  nerve,  320 
from  scorbutus,  302 
total  arrest  of,  321 
Salomon's  test  for  gastric  carcinoma,  86 
Salpingitis  and  nervous  dyspepsia,  419 
Salvarsan.     See  Arsphenamine. 
Salvatose,  188 

Sanatogen  compared  with  milk,  192 
Santonin,  effects  of,  802 
Sarcinse  in  stomach  contents,  92 
Sarcoma  of  alveolar  processes,  346 

and  carcinoma  of  stomach,  differ- 
ential diagnosis  of,  554 
of  esophagus,  364 
of  intestine,  766 
of  liver,  601 
of  maxillae,  346 
of  palate,  341 
of  rectum,  834 
of  stomach,  diagnosis  of,  554 
etiology  of,  553 
pathology  of,  553 
symptoms  of,  553 
treatment  of,  554 
of  tongue,  341 
Scarlet  fever,  diseases  of  salivary  gland 
and,  329 
the  tongue  in,  301 
red  in  gastric  ulcer,  505 
Schmidt's  and  Strasburger's  contribu- 
tion to  fecal  analysis,  112,  172 
diet,  112 
incubator   test    for    fermentation 

and  putrefaction  of  feces,  116 
sublimate  test  for  fecal  pigment, 

116 
test  diet  before  fecal  examination, 
112 
for  nuclei  in  feces,  126 
Schreiber's  esophageal  dilator,  370 
Scleroderma  in  mouth,  318 
Scleroma,  315 

treatment  of,  315 
Scolecitis,  767 
Scolecoiditis,  767 


Scorbutic  stomatitis,  302 
Scotch  douche,  251 
Scurvy  from  vitamin  deficiency,  158 
Sea  baths,  256 

Sea-water  in  cholera  morbus,  642 
dispensaries,  642 
in  infantile  gastroenteritis,  643 
in  membranous  enteritis,  657 
in  nervous  dyspepsia,  423 
technic  of  injection  of,  424 
Seat  worm,  803 
Secretin,  55,  57,  258,  259 
Secretion.      See  Gastric  secretion  and 

Pancreatic  secretion. 
Secretory  disorders  of  mouth,  321 

neuroses,  430,  440 
Sedatives,  gastric,  268 

intestinal,  274 
Segmenting  movements  of  intestine,  62 
Senator's  esophageal  dilator,  370 
Sennatin  in  atonic  constipation,  667 
Sensory  neuroses,  410 
"Sentinel  pile"  of  anal  fissure,  859 
Sepsis,  oral,  290 

Serologic    reactions    in    gastric    carci- 
noma, 543 
Serum  treatment  of  febrilis  icterus,  588 
of  trichinosis,  820 
Trunecek's,  532 
Sevetol,  194 
Sexual  excesses  as  a  cause  of  nervous 

dyspepsia,  419 
Shad-belly,  811 
Sialadenitis,  328 
Sialodochitis,  327 
Sialoliths,  327 

Sigmoid  flexure,  deviations  of,  shown  by 
Roentgen  ray,  148 
positional  changes  of,  in  gas- 
troenteroptosis,  560 
redundant,  560 
Sigmoidal  diverticula,  787,  788 
diverticulitis,  786,  789 

etiology    and    pathology    of, 

786,  788 
roentgenography  in,  790 
symptoms  of,  789 
inflammation,  785.     See  Sigmoid- 
itis, 
origin  of  intestinal  affections,  785 
Sigmoiditis,  chronic,  644.     See  Intesti- 
nal catarrh,  chronic, 
ulcerative,  730 
Sigmoidoscope,    pneumatic    (Strauss), 

237 
Silver  nitrate  in  gastric  diseases,  267 

poisoning,  oral  effect  of,  301 
Singultus  gastricus,  408 

treatment  of,  408 
Sinusoidal    current    in    digestive    dis- 
orders, 219 
Sippy's  esophageal  dilator,  369,  370 
treatment  of  gastric  ulcer,  449 
Skin  diseases  in  esophagus,  357 
in  mouth,  316 


INDEX 


s<)7 


Sleep  after  eating,  171 
Sodium  cacodylate  in  nervous  dyspep- 
sia, 125 
chlorid  waters,  '_'.">.'; 
Sodium-salvarsan,  53  I 
Somatine,  188 
Somatose,  187 

from  milk,  192 
Sounds,  diverticular,  376 
esophageal,  365,  367 
(noises  I,  deglutition,  350 
Soups  in  putrefactive  intestinal  diseases, 

178 
Spasms  from  vagotonia,  3S9 
Spastic   constipation,   668.    See  Con- 

stipation. 
Spices  in  the  diet,  167 
Splanchnoptosis,  557 
Spleen  outlined  by  Roentgen  ray,  150 
Splenoptosis,  569 
Sprue,  308 
Starch  agar  tubes,  102 

conversion,  stages  of,  50 
in  the  stool,  121 
Starck's  diverticular  sound,  376 
Steapsin,  58 

in  feces,  demonstration  of,  125 
Grutzner-Gamgee  test  for,  126 
von  Oefele  test  for,  126 
Steatorrhea,  127 

Stenoses,    intestinal,  roentgenograph^ 
appearance  of,  148 
pyloric,  96.     See  Pyloric  stenosis, 
test-diet  stools  in,  134 
.  Stercoral  ulcers,  736 
Stockton's  combined  stomach  tube  and 

electrode,  218 
Stomach,  absorptive  power  of,  56,  89 
atony  of,  95.     See  also  Atony  of 
stomach,    and    Motor    in- 
sufficiency, 
shown    by    roentgenography, 
140 
bucket,  Einhorn's,  70 
carbolrydrate  digestion  in,  85 
carcinoma  of,  537.     See  Carcinoma 

of  stomach. 
cells  and  their  function,  54 
condition  of,  in  constipation,  185 
contents  in  achylia  gastrica,  95 
acidity    of.    See    Acidity    of 

stomach  contents, 
aspiration  method  of  obtain- 
ing, 68 
in  atony,  95 
bile  in,  66 
blood  in,  66,  86 

Weber's  guaiac  test  for, 
86 
Boas-Oppler  bacillus  in,  92 
Chase's    stomach     tube     for 

obtaining,  206 
crystals  in,  94 

determination  of  gastric  juice 
in,  73 
57 


Stomach    contents,    determination  of 
read  ion  of,  7"> 
in  diarrhea,  <>7r> 
in  erosions  of  stomach,  07 

examination  of,  <i<> 
chemical,  74 
for  enzymes,  83 
indirect,  88 
macroscopic,  68 
microscopic,  92 
filtration  of,  reason  for,  78 
food  remnants  in,  96 
fractional  analysis  of,  78 
in  gastric  atony,  95 
carcinoma,  97 
dilatation,  95 
neuroses,  94 
ulcer,  97 
in  gastritis,  95 
HC1  free  and  combined  in,  75- 

81 
in  hyperacidity,  94 
in  hypersecretion,  94 
indirect  methods  of  analyzing, 

88 
inspection  of,  72 
lactic  acid  in,  82 
methods  for  obtaining,  68 
aspiration,  68 
expression,  68 
regurgitation,  71 
with  stomach  bucket, 
72 
in  motor  insufficiency,  92,  95 
mould  fungi  in,  92 
mucous  membrane  in,  94 
normal  acidity  of,  78 
protozoa  in,  92 
in  pyloric  insufficiency,  96 

stenosis,  96 
phenolphthalein  test  for  total 

acidity  of,  79 
quantitative  analysis  of,  76 
fractional,  78 
normal  solutions  for, 

77 
phenolphthalein  test 

in,  79 
Topfer's  method,  80 
quantity  of,  73 
reaction  of,  75 
retention  of,  208 
sarcinse  in,  92 
tests  for  HC1  in,  75,  76 

for  lactic  acid  in,  82,  83 
cowhorn,  389 
cysts  of,  555 
digestive  function  of,  52 

Giinzburg's  test  of,  89 
Sahli's  test  of,  90 
dilatation  of,  95.     See  Dilatation 

of  stomach, 
douche,  205 

Einhorn's,  206 
Rosenheim's,  205 


898 


INDEX 


Stomach  douche,  Turck's,  206 
electrization  of,  215 
electrode,  216,  217 

and  tube,  Stockton's,  218 
Boas',  216 
Einhorn's,  217 

Lockwood's  modification 
of,  217 
Wegele's,  217 
erosions  of,  97,  521.     See  Erosions 

of  stomach, 
fibroma  of,  555 
fibromyoma  of,  555 
form  of,  139 

hemorrhage  from,  511.     See  Hem- 
orrhage, 
hour-glass,  142,  524 

pseudo,  139 
hunger  contractions  of,  64 
hyperesthesia  of,  413 
hypermotility  of,  392 
lavage,  197 
lipoma  of,  555 
massage,  208 
motor  function  of,  90.     See  Motor 

function  of  stomach, 
mould  fungi  in,  92 
movements  of,  50 

shown    by    roentgenography, 
51,  140 
nerve  supply  of,  52 
neuralgia  of,  410 
neuroses  of,  387 
normal  outline  of,  138 
peristalsis  of,  51 
peristaltic  unrest  of,  392 

waves,  double,  in,  139 
Roentgen-ray  examination  of,  138 
sarcinse  in,  92 
sarcoma  of,  553.     See  Sarcoma  of 

stomach, 
syphilis  of,  533 
tetany  of,  485 
tonus  of,  140 

shown    by    roentgenography, 
51,  140 
tube,  69,  70,  199,  200,  203,  204 
f6r  aspiration,  Chase's,  207 
and  bulb,  Aaron's,  69,  70 
and  electrode,  Stockton's,  218 
and  funnel,  200 
Friedlieb's,  203 
introduction  of,  202 
perforated  (Rosenheim's),  205 
Rehfuss',  78 
Strauss',  204 
Turck's,  206 
use  of,  by  patients,  202 
tuberculosis  of,  536 
tumors  of,  537,  555 
ulcer  of,  488.     See  Ulcer,  gastric, 
water-trap,  139,  558 
See  also  Gastric. 
Stomach-ache,  414 
Stomachic,  condurango  as  a,  267 


Stomachic,  HC1  as  a,  260 

orexin  as  a,  267 
Stomachics,  action  of,  266 
Stomatitis,  aphthous,"  307 
treatment  of,  308 
erysipelatous,  307 

treatment  of,  307 
from  bismuth,  300 
from  gout,  303 
from  influenza,  302 
from  lead,  301 
from  mercury,  299 
from  phosphorus,  301 
from  scorbutus,  302 
from  variola,  302 
gangrenous,  305 

treatment  of,  306 
hair-tongue  and,  323 
in  infantile  scurvy,  303 
of  lingua  geographica,  323 
noma,  306 

treatment  of  307 
simple  or  catarrhal,  305 

treatment  of,  305 
sprue,  308 
thrush,  309 

treatment  of,  309 
ulcerosa,  306 
Stools,  pathologic,  in  diagnosis,  119. 
See  also  Feces,  and  Test-diet  stool 
findings. 
Strasburger's      fermentation       tubes, 
117 
method  of  separating  bacteria  from 
feces,  118 
Strauch  and  the  nuclei  test  of  Adolf 

Schmidt,  126 
Strauss'  funnel  for  lactic  acid  test,  82 
sigmoidoscope,  237 
suction  tube,  204 
test  for  lactic  acid,  83 
Streptococci,  transmutation  of,  291 
Streptococcus-pneumococcus  group  of 
organisms,  293 
viridans,  292 
Stricture  of  duodenum,  755 
symptoms  of,  755 
of  esophagus,  361,  383 
dilatation  of,  364 
of  ileum,  756 
of  intestine,  755 
diet  in,  759 
infrapapillary,  755 
lavage  in,  759 
liquid  petrolatum  in,  760 
purgatives  in,  760 
suprapapillary,  755 
treatment  of,  758 
of  jejunum,  756 
of  large  intestine,  757 

consequences  of,  758 
etiology  of,  758 
roentgenography  in  diag- 
nosis of,  757 
symptoms  of,  757 


INDEX 


siMi 


Stricture  of  rectum,  837.    See   Rectal 
stricture 
of  small  intestine,  755 

roentgenography  in  diag- 
nosis of,  756 
String  test  in  cardiospasm,  398 

in  diagnosis  of  gastric  ulcer, 

493 
in  pylorospasm,  399 
Strongyloides  stercoralis,  816 
Strongylus  duodenalis,  806 
Struma  at  base  of  tongue,  339 
Strychnin     as     an     aid     to    intestinal 
peristalsis,  28 1 
in  diarrhea,  407 
in  gastric  diseases,  266 
in  gastrogenic  diarrhea,  677 
in  pyloric  insufficiency,  266,  407 
Subacidity,  silver  nitrate  in,  268 

test-diet  stool  findings  in,  131, 673 
Subcutaneous  nutrition  in  motor  in- 
sufficiency, 482 
Sublimate  test  for  fecal  pigment,  116 
Suction  tube,  202 

with  double  bulb,  204 
Sugar  in  constipation,  185 

in  diet  of  gastric  patients,  167 
effect  of,  on  gastric  secretion,  167 
Sugars  as  aperients,  284 
Sulphur  as  a  purgative,  285 
Sulphuric  acid  poisoning,  fatality  of, 

357 
Suppuration  shown  by  fecal  examina- 
tion, 122 
Surgery     of     stomach     or     intestine, 

lavage  preceding,  197 
Surgical  bladder  from  trematodes,  818 

kidney  from  trematodes,  818 
Swallowing  sounds,  350 
Swedish  manipulation  in  chronic  con- 
stipation, 228 
Sympathetic  nerve  plexuses  accessible 

by  massage,  214 
Sympathicotonia,  388 

signs  of,  391 
Syphilis  and  arteriosclerosis,  528 
of  esophagus,  359 
of  liver,  599 
of  mouth,  309 
primary,  309 

treatment  of,  310 
secondary,  310 

treatment  of,  311 
tertiary,  311 

treatment  of,  312 
of  salivary  glands,  329 
of  stomach,  533 

diagnosis  of,  533 
treatment  of,  534 
general,  535 
specific,  534 
Syphilitic  plaques  in  mouth,  310 
ulcers  of  intestine,  741 
of  rectum,  843 
Syringe,  esophageal,  354 


T \iu.s,  pyorrhea  in,  333 
Taenia  Baginata,  7'.tt,  795 

Milium.  7!l  I.  796 
Tampons,   rectal,   in   chronic  constipa- 
tion, 230 
Tannalbin,  277 

Tannic  acid  in  intestinal  diseases.  _'77 
Tannigen,  277 
Tannocol,  277 
Tannoform,  277 
Tannyl,  277 
Tapeworms,  794 

aspidium  (male  fern)  in  treatment 

of,  797 
bothriocephalus  latus,  794,  797 
castor  oil  in  treatment  of,  799 
diagnosis  of,  796 
hemenolepis  nana,  794,  798 
mode  of  infection  with,  795 
pelletierin  in  treatment  of,  799 
pumpkin    seed    in    treatment  of, 

799 
symptoms  of,  795 
taenia  saginata,  794,  795 

solium,  794,  796 
treatment  of,  797 
Tapotement,  209,  213 
Tea,  effect  of,  on  digestion,  169 
Teeth,  carious,  and  phlegmon,  330 
details  in  care  of,  294 
swallowed,   located   by   Roentgen 
ray,  377 
Telangiectasia  of  mouth,  336 
Temperature  of  food  in  constipation, 

185 
Terrell's  treatment  of  internal  hemor- 
rhoids, 829 
Test  breakfast,  Boas',  67 
Ewald-Boas',  67 
diet  and  its  administration,  67,  112 
to  determine  intestinal  func- 
tion, 112 
stool,  examination  of,  114 
chemical,  116 
macroscopic,  115 " 
microscopic,  115 
findings  in   achylia   gas- 
trica      and      sub- 
acidity,  131 
in    atonic    constipa- 
tion, 133 
in  chronic  constipa- 
tion, 661 
in  duodenal  ulcer,  133 
in  dysentery,  133 
in  enteritis  membra- 

nacea,  133 
in  gastric  carcinoma, 
131 
ulcer,  131 
in  hyperacidity,  131 
in  intestinal  carcino- 
ma, 134 


900 


INDEX 


Test -diet    stool    findings    in    intesti- 
nal   catarrh, 
chronic,    131, 
132 
fermentative 
dyspepsia, 
134,  678 
tuberculosis,  133 
in  nervous  diarrhea, 

134,681 
in   spastic  constipa- 
tion, 134, 670 
in  stenoses,  134 
in    subacidity,    131, 
673 
dinner,  Biegel's,  68 
meal,  Einhorn's,  before  examining 
duodenal  contents,  101 
Leube's,  before  exaniining  duo- 
denal contents,  90 
normal,  118 
Schmidt's,    before   examining 

feces,  112 
in  treatment,  179 
Tests  for  blood  in  feces,  123 

in  gastric  contents,  66,  86 
for  carcinoma  of  stomach,  86-88 
for  diastase,  127 

for  dissolved  protein  in  feces,  117 
for  enzymes,  83,  102 
for  fat  in  feces,  127 
for  fecal  pigment,  116 
for  fermentation  and  putrefaction 

of  feces,  116 
for  gastric  absorption.  89 
aciditv,  78-81,  88-90     ' 
function,  89,  90 
motility,  90,  91,  129 
secretion.  90 
for  hepatic  insufficiency,  592-593 
for  hydrochloric  acid,  75-81,  88-90 
for  intestinal  motility,  128,  129 
for  lactic  acid,  82,  83 
for  lipase.  592 
for  nuclei  in  feces,  126 
for  pancreatic  function,  126,  129, 

624-629 
for  pepsin  and  HC1,  84 
for  peptone,  85 
for  propeptone,  85 
for  steapsin,  125 
string,  396,  399,  493,  710 
for  trypsin,  125,  126 
for  urobilin,  101 

for  vagotonia  and  sympathicoto- 
nia, 391 
Tetany,  gastric,  485 

lavage  in,  198 
Thermos  proctoclysis  apparatus,  242 
Thiosinamin  in  pyloric  stenosis,  484 
Thread  test  for  gastric  acidity,  88 
worm,  803 

anthehmintics  in,  805 
calcification  of,  803 
diagnosis  of,  804 


Thread  worm,  diet  in,  805 

disinfection  during  treatment 

of,  805 
enemata  in,  805,  806 
fife  history  of,  803 
symptoms  of,  803 
treatment  of,  805 
Thrombotic  ulcers  of  intestine,  741 
Thrush,  309 

of  esophagus,  361,  378 
treatment  of,  309 
Thyroid  extract  in  arteriosclerosis,  532 
Tobacco  in  gastric  disease,  169 
Tongue,  abscess  of,  324 
affections,  322 
angioma  of,  336 
carcinoma  of,  343 
coating  of,  322 
cysts,  338,  339 
endothelioma  of,  340 
enlargement  of  (macroglossia),  326 
fibroma  of,  335 
furrowed,  326 
geographic    (lingua    geographica), 

323 
hair  (lingua  nigra),  323 
inflammation  of  (glossitis),  324,325 
lipoma  of,  335 
lymphangioma  of,  337 
lymphoma  of,  327 
malformation  of,  322 
neuralgia  of,  321 
pain  (glossodynia),  321 
papilloma  of,  340 
phlegmon  of  (acute  diffused  glos- 
sitis), 324 
sarcoma  of,  341 
in  scarlet  fever,  301 
struma  of,  339 
tuberculosis  of,  313 
ulcers  of,  305,  325 
Tonsil,  hypertrophy  of,  326",  347 

lingual,  hyperkeratosis  of,  327 
Tonsillitis  as  a  cause  of  other  infections, 
292 
chronic.  347 
follicular,  347 
lingual,  326 
parenchymatous,  347 
suppurative,  347 
Tonus  of  digestive  tract,  fundamental 
or  extrinsic,  64 
of  stomach  shown  by  Roentgen 
ray,  140 
Tooth    pastes    and    powders    recom- 
mended, 294 
Topfer's  method  of  quantitative  analy- 
sis in  determining  gastric  acidity,  80 
Tormina  intestinorum  nervosa,  782 
symptoms  of,  782 
treatment  of,  782 
Toxemia  and  arteriosclerosis,  529 
and  oral  sepsis,  290 
of  ileus,  747 
intestinal,  683 


INDEX 


901 


Toxic  gastritis,  155 

products  of  bacteria  conditioned 
on    culture    medium,  684, 
685 
of  intestinal  putrefaction,  080 
Trematodes,  816 

biliary  calculi  from,  818 
cirrhosis  from,  818 
dysentery  from,  818 
in  portal  vein,  817 
somatic  habitat  of,  817 
surgical  bladder  from,  818 

kidney  from,  818 
treatment  of,  bib 
Trichina  spiralis,  818,  819 
Trichiiue  in  intestine,  818 

in  muscle,  S19 
Trichinosis,  diagnosis  of,  820 
eosinophilia  in,  819 
how  to  prevent,  100 
raw  meat  and,  100 
symptoms  of,  819 
treatment  of,  820 

with  immune  serum,  820 
Trichocephalus  dispar,  814 
Trophic  disorders  of  mouth,  321 
Tropon,  188 
Trunecek's  serum,  532 
Truss,  Esmarch's  rectal,  847 
Trypsin,  57 

in  feces,  Gross'  casein  test  for,  125 
Muller-Schlect  test  for,  125 
Schmidt's  nuclei  test  for,  126 
Tripsinogen,  58 
Tube,  colon,  220 

duodenal,  Einhorn's,  98 
Gross',  100 
Kuhn's,  98 
Jutte's,  100 
Palefski's,  100 
gastroduodenal,  Rehfuss',  78 
irrigating,  Rosenberg's,  234 
Wolbarst's,  234 
Zweig's,  233 
Leiter's,  250 
rectal,  221 

stomach,  Aaron's  improved,  68-70 
Chase's,  207 
Friedlieb's,  203 
Rehfuss',  78 
Rosenheim's,  205 
Strauss',  204 
Turck'  s  double  flow,  206 
with  electrode,  Stockton's,21S 
with  funnel  connection,  200 
Tubercle  bacilli  in  feces,  122 

gastric  juice  and,  737 
Tubercular  abscess  of  pharynx,  348 

intestinal  ulcers,  737 
Tuberculosis  of  cecum,  740 
of  esophagus,  359 
of  intestine,  737 

test-diet  stool  findings  in,  133 
of  liver,  600 
of  mouth,  312 


Tuberculosis  of  stomach,  536 

of  tongue,  3 13 
Tumors,  benign,  of  esophagus,  362 

of  gall  bladder,  014 
of  intestine,  766 
of  liver,  602 
of  maxilla-,  345 
of  mouth.  335 
of  stomach,  555 
of  pancreas,  633 

malignant.     See  Carcinoma,    Sar- 
coma, etc. 
Turck's  double-flow  stomach  douche, 

206 
Tympanites,  698 
Typhlitis  stercoralis,  736 
Typhoid  carriers,  duodenal  contents  of, 
110 
fever,  danger  of  acidosis  in  diet  of, 
716 
diet,  carbohydrates  in,  716 
fat  in,  716 
high  caloric,  714 
need  of  sodium  chlorid  in, 

715 
starch  in,  716 
diseases    of    salivary    glands 

and,  329 
duodenal  contents  in,  110 
Houghton's  diet  table  for,  717 
palatal  ulceration  in,  302 
recrudescences  as  affected  by 

diet,  714 
vegetable  soup  in,  preparation 
of,  717 
ulcers,  713 


Uffelmax's  test  for  lactic  acid,  82 
Ulcer,  alveolar,  321 

callous,    roentgenologic    diagnosis 

of,  141 
colitic,  dry  treatment  of,  237 
duodenal,  705 

affecting  form  of  stomach,  144 
age  incidence  of,  710 
appendicitis  and,  708 
blood  test  in  diagnosis  of,  709 
cholelithiasis  and,  708 
chronic  cholecystitis  and,  708 

constipation  and,  708 
comfort  posture  of  patient  in, 

709 
complications  of,  710 
diagnosis  of,  143,  707 
by  posture,  709 
roentgenographic,  143,  710 
by  silk  string  test,  710 
diet  in,  711 

duodenal  contents  in,  1 10 
etiology  of,  705 
fecal  examination  in,  133,  709 
gastric  secretion  in,  709 


902 


INDEX 


Ulcer,  duodenal,  hemorrhage  from,  707 
marasmus  and,  710 
melena  of  infants  and,  710 
pain  of,  708 
perforated,  708 
perforating,  an  indication  of, 

144  . 
peristalsis  in,  144 
polycythemia  in,  710 
prognosis  of,  711 
sex  incidence  of,  710 
symptoms  of,  706 
test-diet  stool  findings  in,  133 
treatment  of,  internal,  711 
surgical,  712 
experimental,  706 
gastric,  97,  488 

age  incidence  of,  489 
antilytic  serum  in,  506 
appetite  in,  492 
bacterial  vaccines  in,  506 
bismuth  in,  504 

subnitrate  in,  266,  504 
callous,   roentgenography   of 

141 
complications  of,  493 
diagnosis  of,  493 

by  string  test,  493 
duodenal  alimentation  in,  500 
effect  of  healing  of,  490 
etiology  of,  489 
frequency  of,  489 
from  arteriosclerosis,  528 
hemorrhage  from,  491 
incidence  of  vomiting  in,  491 
incisura  in,  139 
localization  of  pain  in,  491 
mud-baths  in,  257 
olive  oil  in,  506 
pathology  of,  488 
perforating,  488 

diagnosis  of,  492 

roentgenography  of,  181 
perforation  from,  492,  509 
prognosis  of,  494 
prophylaxis  of,  495 
in  pruritus  ani,  851 
pyloric  stenosis  in,  509 
roentgenography  of,  141 
scarlet  red  in,  505 
sequelae  of,  493 
sex  predisposition  to,  489 
silver  nitrate  in,  505 
stomach  contents  in,  97 
subphrenic  abscess  following 

perforation  in,  509 
surgery  in,  507 
symptoms  of,  490 
test-diet  stool  findings  in,  131 
treatment   of,   antigenic    (by 
vaccines),  506 

Lenhartz,  498 

Leube-Ziemssen,  495 

medicinal,  503 

Sippy,  499 


Ulcer,  gastric,  treatment  of,  surgical,  507 
vomiting  in,  491 
jejunal,  712 
palatal,  321 
peptic,  488 
perforating,       demonstrated       by 

Roentgen  ray,  141  « 

round,  488 

of  tongue,  decubital,  325.    See  atso 
Ulcers. 
Ulcerative  colitis,  730 
enteritis,  730 
perisigmoiditis,  789 
sigmoiditis,  730 
Ulcerocarcinoma,  541 
Ulcers,  dysenteric,  719.   See  Dysentery, 
of  esophagus,  358 
intestinal,  705,  713,  719,  730,  737 
catarrhal  and  follicular,   730. 

See  also  Enteritis, 
diet  in,  172 
embolic,  741 
syphilitic,  741 
thrombotic,  741 
tubercular,  737.     See  Intesti- 
nal tuberculosis, 
of  palate,  304 
of  rectum,  843 

anodynes  in,  844 
diagnosis  of,  844 
gonorrheal,  843 
surgery  of,  845 
syphilitic,  843 
treatment  of,  844 
tubercular,  844 
stercoral  or  decubital,  736 
tibial,  in  hookworm  disease,  811 
of  tongue,  305 

typhoid,  713.     See  Typhoid  fever. 
See  also  Ulcer. 
Ulcus  rotundum  duodeni,  705 

ventriculi,  488 
Umbilical  dyspepsia,  428    . 
Uncinaria  americana,  809 

duodenalis,  806 
Uncinariasis,    806.       See    Hookworm 

disease. 
Urethritis  from  trematodes,  818 
Urobilin  and  urobilinogen  in  duodenal 
contents,  101,  110 
Schlesinger's  test  for,  101 
Urobilinuria  from  disease  of  liver,  593 
Urticaria  in  mouth,  318 
Uvula,  carcinoma  of,  344 
Uzara,  276 


Vaccine  treatment    of   chronic   intes- 
tinal catarrh,  649 
of  enteritis  membranacea,  656 
of  gastric  ulcer,  506 
of  pruritus  ani,  856 
of  ulcerative  colitis,  735 


INDEX 


<»<>:; 


Vaccine  treatment  of  ulcerative  enter- 
itis, 735 
Vaccinia  in  mouth,  302 
Vagotonia,  389 

and  mucous  colitis,  653 
and  sympathicotonia,  388 
medical  t  reatment  of,  391,  056,  058 
signs  of,  390,  391 
Vagus  and  sympathetic,  coordination 
of,  781 
gastric  secretion  and,  54 
Varicella,  oral  localization  of,  302 
Vari<  >la,  diseases  of  salivary  glands  and, 
329 
in  esophagus,  357 
Variolous  stomatitis,  302 
Vasomotor  disorders  of  mouth,  321 
Vegetable  milk,  194 

protein  preparations,  191 
Vegetables    in    constipating    diet    of 
intestinal  diseases,  179 
green,  in  diet  of  gastric  patients, 
107 
Vegetative  nervous  system,  387,  781 

diagnosis  of  disturbances 

of,  390 
spastic  constipation  and, 
068 
Verneuil's  dilatation  treatment  of  hem- 
orrhoids, 827 
Vertebral  massage  in  peristaltic  unrest 
of  stomach,  393 
pain  in  gastric  ulcer,  491 
pressure  and  pyloric  function,  211, 

405 
symptoms   of  pancreatic  disease, 
627 
Vibration  following  massage,  214 
Vitamin,  157 

deficiency,  effects  of,  158 

foods  rich  in,  158 

growth-promoting,  159 

in  milk,  157 

necessity  of,  157 

in  rice,  157 

susceptibility    of,     to    heat    and 

alkalis,  158 
three  kinds  of,  158 
Volvulus     of     cecum     diagnosed     by 
Roentgen  ray,  147 
hemorrhage  from,  747 
massage  in,  749 
origin  of,  742 
of  sigmoid,  748 
Vomiting  in  gastric  ulcer,  491 
hysterical,  electricity  in,  215 
idiopathic,  403 
of  intestinal  stricture,  755 
lavage  in,  197,  198 
to  prevent,  197 
nervous,  403 

treatment  of,  404 
of  peritonitis,  lavage  in,  198 
of  pregnancy,  blood  transfusion  in, 
404 


Vomiting  of  pregnancy,  corpus  luteum 
in,  10.") 
electricity  in,  21.", 
epineplirin  in,  404 
vertebral  percussion  in,  405 
Von  Oefele's  test  for  steapsin  in  feces, 
120 


W 


\\alks  bougie,  733 
Warm  entire  pack,  248 
Water  in  the  diet,  168 

effect  of,  on  gastric  secretion,  168 
hot,  before  meals,  168 
mineral,  in  gastric  diseases,  168 
retention  of,  in  stomach,  168 
in  therapeutics,  247 
"Water  way"  in  stomach,  52 
Water-trap  stomach,  139,  558 
Waters,  alkaline  carbonated,  253 
bitter,  254 
chlorin,  252 
furruginous,  254 
sodium  chlorid,  253 
Weber's  guaiac  test  for  blood  in  gastric 

contents,  86 
Wegele  s  stomach  electrode,  217 
Weil's  disease,  587 
Wet  rub,  the,  247 
Whey  in  the  diet,  164 
Whipworm,  814 

treatment  of,  815 
Whortleberry  as  an  astringent  article 

of  diet,  177 
Williams'  hemorrhoidal  electrode,  831, 

832 
Wohlgemuth's  antidiabetic  diet  in  pan- 
creatic disease,  630 
test  for  diastase  in  feces,  127 
Wolbarst's  rectal  irrigation  tube,  235 
Wolff-Junghans  test  for  gastric  carci- 
noma, 87 
Worm  carriers,  813 

Worms,  794.     See  Tapeworm,  Round 
worm,  Thread  worm,  Hookworm, 
Whipworm;  Anguillula,  Trema- 
todes,  and  Trichina, 
appendicitis  and,  767 
eosinophilia  and,  800 
maggot,  803 

nervous  djrspepsia  and,  419 
Wormseed,  American,  as  a  substitute 
for  santonin,  802 


Xerophthalmia 

ciency,  158 
Xerostomia,  321 


from    vitamin    defi- 


904 


INDEX 


Yaoita's  method  of  diagnosing  tape- 
worm, 796 
Yeast  in  chronic  constipation,  666 

as  an  intestinal  disinfectant,  281 
Yoghurt,  165 

advantages  of,  165 

from  tablets,  165 

in  gastric  diseases,  165 

in  intestinal  toxemia,  692 

kefir,    koumiss    and    sour    milk, 
comparison  of,  165 

life-prolonging  effect  of,  165 


Yoghurt,  nutritive  value  of,  164 
Young's     apparatus     for     continuous 
proctoclysis,  242 


Zweig's    ice-bag    for    painful    hemor- 
rhoids, 824 
oil  enemator,  223 
rectal  electrode,  231 
irrigating  tube,  233 
Zymogens,  53 


KC  801         n<*7 


